Healthcare Provider Details

I. General information

NPI: 1154834786
Provider Name (Legal Business Name): JORDAN MARCOU PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2017
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5520 PARK AVE
TRUMBULL CT
06611
US

IV. Provider business mailing address

52 BEACH RD STE 104
FAIRFIELD CT
06824-6692
US

V. Phone/Fax

Practice location:
  • Phone: 203-373-7330
  • Fax:
Mailing address:
  • Phone: 203-254-3570
  • Fax: 203-255-3126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4008
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: