Provider Demographics
NPI:1265872105
Name:BETHEA, JORDYN DEBORAH (PA-C)
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:DEBORAH
Last Name:BETHEA
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 1:414 LIGHT ST UNIT 4201
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-1347
Mailing Address - Country:US
Mailing Address - Phone:732-310-8214
Mailing Address - Fax:561-498-0320
Practice Address - Street 1:3001 S HANOVER ST STE 216A
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-1233
Practice Address - Country:US
Practice Address - Phone:410-350-2106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-25
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007175363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018266800Medicaid