Healthcare Provider Details

I. General information

NPI: 1104386614
Provider Name (Legal Business Name): JORDAN PHILLIPS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 OGLETHORPE AVE STE C7
ATHENS GA
30606-2221
US

IV. Provider business mailing address

700 OGLETHORPE AVE STE C7
ATHENS GA
30606-2221
US

V. Phone/Fax

Practice location:
  • Phone: 706-425-9445
  • Fax: 706-425-0820
Mailing address:
  • Phone: 706-425-9445
  • Fax: 706-425-0820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number99863
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2021-02070
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: