Provider Demographics
NPI:1770058224
Name:CLEMENTE, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:CLEMENTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2158 EXCHANGE ST # 304
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3316
Mailing Address - Country:US
Mailing Address - Phone:503-325-8315
Mailing Address - Fax:503-325-8602
Practice Address - Street 1:2158 EXCHANGE ST # 304
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3316
Practice Address - Country:US
Practice Address - Phone:503-325-8315
Practice Address - Fax:503-325-8602
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA195841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant