MEDICARE: JORDAN COLE PETITT MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1780390260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN COLE PETITT MD

Provider Business Mailing Address
First Line	:	7400 SEABROOK LN
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22153-2155
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9500 EUCLID AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44195-2155
Country	:	US
Telephone Number	:	216-444-2200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2023
Last Update Date	:	03/27/2024

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