=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013446103
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN THOMAS HOUSTON PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 519 STEPHENSON AVE
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31405-5969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-354-9447
-----------------------------------------------------
Fax | 912-401-0741
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 519 STEPHENSON AVE
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31405-5969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-354-9447
-----------------------------------------------------
Fax | 912-401-0741
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 008366
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------