Provider Demographics
NPI:1992364970
Name:GOOCH, JORDAN TAYLOR (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:TAYLOR
Last Name:GOOCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8415 DATAPOINT DR STE 700
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3327
Mailing Address - Country:US
Mailing Address - Phone:210-614-1234
Mailing Address - Fax:
Practice Address - Street 1:12850 TOEPPERWEIN RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-4115
Practice Address - Country:US
Practice Address - Phone:210-614-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA12911363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant