Healthcare Provider Details

I. General information

NPI: 1164092185
Provider Name (Legal Business Name): DAKOTA JORDAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 S UNION BLVD STE 315
COLORADO SPRINGS CO
80910-3126
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 150
LOVELAND CO
80538-9071
US

V. Phone/Fax

Practice location:
  • Phone: 719-365-3700
  • Fax:
Mailing address:
  • Phone: 970-624-4034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberPA.0006813
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0006813
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: