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General NPI Number Information
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NPI Number | 1366795395
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Entity Type | Individual
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Provider Name | TARA MARIE JORDAN MMS, PA-C
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Gender | Female
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Dates
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Enumeration Date | 10/15/2012
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Last Update Date | 08/13/2014
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Provider Practice Location Address
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Address Line | 20055 LAKE CHABOT RD SUITE 130
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City | CASTRO VALLEY
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State | CA
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Zip | 94546-5331
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Country | US
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Telephone | 510-888-0657
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Fax |
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Provider Business Mailing Address
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Address Line | 2125 SANTA CLARA AVE APT J
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City | ALAMEDA
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State | CA
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Zip | 94501-2812
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Country | US
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Telephone |
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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 | PA22633
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License Number State | CA
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