Healthcare Provider Details

I. General information

NPI: 1710424254
Provider Name (Legal Business Name): JORDAN STORES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2017
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1544 COUNTY ROAD 220 STE 100
ORANGE PARK FL
32003-4991
US

IV. Provider business mailing address

1959 MOORINGS CIR
MIDDLEBURG FL
32068-6645
US

V. Phone/Fax

Practice location:
  • Phone: 904-223-2340
  • Fax: 904-637-7991
Mailing address:
  • Phone: 904-662-0310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113597
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: