Provider Demographics
NPI:1255997748
Name:JORDAN, AUTUMN (MD)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:JORDAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 287
Mailing Address - Street 2:
Mailing Address - City:TERRA CEIA
Mailing Address - State:FL
Mailing Address - Zip Code:34250-0287
Mailing Address - Country:US
Mailing Address - Phone:978-886-2788
Mailing Address - Fax:
Practice Address - Street 1:2150 PENNSYLVANIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-3201
Practice Address - Country:US
Practice Address - Phone:202-741-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101275788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program