Healthcare Provider Details

I. General information

NPI: 1255703088
Provider Name (Legal Business Name): TINA JORDAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4631 BILL GARDNER PKWY
LOCUST GROVE GA
30248-2437
US

IV. Provider business mailing address

4631 BILL GARDNER PKWY
LOCUST GROVE GA
30248-2437
US

V. Phone/Fax

Practice location:
  • Phone: 770-630-6281
  • Fax: 678-272-0001
Mailing address:
  • Phone: 770-630-6281
  • Fax: 678-272-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN 98431
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: