Healthcare Provider Details

I. General information

NPI: 1386845535
Provider Name (Legal Business Name): BENJAMIN JORDAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 STEVENS CREEK RD
AUGUSTA GA
30907-9251
US

IV. Provider business mailing address

PO BOX 1705
AUGUSTA GA
30903-1705
US

V. Phone/Fax

Practice location:
  • Phone: 706-724-9607
  • Fax: 706-722-7454
Mailing address:
  • Phone: 706-774-7263
  • Fax: 706-774-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4952
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: