Provider Demographics
NPI:1184110298
Name:GALLINIS, JORDAN LYNNE (PA)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LYNNE
Last Name:GALLINIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:JORDAN
Other - Middle Name:LYNNE
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ATC
Mailing Address - Street 1:PO BOX 802738
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-7874
Mailing Address - Country:US
Mailing Address - Phone:720-375-2008
Mailing Address - Fax:
Practice Address - Street 1:511 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-6962
Practice Address - Country:US
Practice Address - Phone:405-707-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
OK4896363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000033232OtherATHLETIC TRAINING CERTIFICATION