Provider Demographics
NPI:1790516086
Name:WOLFF, JORDAN NICOLE
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:NICOLE
Last Name:WOLFF
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11983 SAN PABLO BAY ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-6159
Mailing Address - Country:US
Mailing Address - Phone:702-493-2250
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4210
Practice Address - Country:US
Practice Address - Phone:864-455-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-09
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5455363A00000X
SC363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant