Healthcare Provider Details

I. General information

NPI: 1003225855
Provider Name (Legal Business Name): JORDAN GALLO JACOBS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6315 S ZARZAMORA ST
SAN ANTONIO TX
78211-3218
US

IV. Provider business mailing address

3750 COMMERCIAL AVE
SAN ANTONIO TX
78221-3117
US

V. Phone/Fax

Practice location:
  • Phone: 210-977-1900
  • Fax: 210-977-9326
Mailing address:
  • Phone: 210-334-3750
  • Fax: 210-922-0162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA09391
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: