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General NPI Number Information
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NPI Number | 1932507092
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Entity Type | Individual
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Provider Name | JORDAN SMITH PA-C
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Gender | Male
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Dates
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Enumeration Date | 12/05/2014
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Last Update Date | 03/25/2021
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Provider Practice Location Address
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Address Line | 9500 MENTOR AVE STE 100
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City | MENTOR
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State | OH
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Zip | 44060-8702
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Country | US
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Telephone | 440-352-4880
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Fax |
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Provider Business Mailing Address
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Address Line | 197 SHORELAND CIR
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City | WILLOWICK
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State | OH
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Zip | 44095-4690
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Country | US
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Telephone | 330-806-9505
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 004178
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License Number State | OH
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