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General NPI Number Information
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NPI Number | 1013347640
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Entity Type | Individual
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Provider Name | JORDAN PERSONIUS PA
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Gender | Male
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Dates
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Enumeration Date | 11/18/2013
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Last Update Date | 11/18/2013
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Provider Practice Location Address
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Address Line | 500 SW RAMSEY AVE
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City | GRANTS PASS
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State | OR
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Zip | 97527-5554
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Country | US
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Telephone | 541-789-4281
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Fax |
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Provider Business Mailing Address
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Address Line | 2620 E BARNETT RD SUITE H
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City | MEDFORD
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State | OR
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Zip | 97504-8344
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Country | US
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Telephone | 541-789-4281
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA165526
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License Number State | OR
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