Provider Demographics
NPI:1881126431
Name:SULLIVAN, JORDAN SCOTT (PA-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:SCOTT
Last Name:SULLIVAN
Suffix:
Gender:M
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 1:325 PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-1617
Mailing Address - Country:US
Mailing Address - Phone:609-924-8131
Mailing Address - Fax:609-924-8532
Practice Address - Street 1:325 PRINCETON AVE
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-1617
Practice Address - Country:US
Practice Address - Phone:609-924-8131
Practice Address - Fax:609-924-8532
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00968363A00000X
NJ25MP00670500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant