Healthcare Provider Details

I. General information

NPI: 1427642479
Provider Name (Legal Business Name): JORDAN CORDOVA CAA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1488 JESSE JEWELL PKWY SE STE 201
GAINESVILLE GA
30501-3803
US

IV. Provider business mailing address

2794 S EATON WAY
DENVER CO
80227-4114
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-9000
  • Fax:
Mailing address:
  • Phone: 303-868-2360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: