Provider Demographics
NPI:1992042923
Name:HOLCOMBE, JORDAN L (PA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:L
Last Name:HOLCOMBE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:L
Other - Last Name:WACKENHUTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6301 HARRIS PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4245
Mailing Address - Country:US
Mailing Address - Phone:817-877-3432
Mailing Address - Fax:817-346-4394
Practice Address - Street 1:6301 HARRIS PKWY STE 300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4245
Practice Address - Country:US
Practice Address - Phone:817-877-3432
Practice Address - Fax:817-346-4394
Is Sole Proprietor?:No
Enumeration Date:2013-01-10
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08329363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX323432001Medicaid
TX288196YKPWMedicare PIN