MEDICARE: JORDAN PIERSON GARNER ROBERTS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA10061	TX
2	363A00000X	Physician Assistant	085005576	IL

General Provider Information

NPI Number	:	1801263801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN PIERSON GARNER ROBERTS PA-C

Provider Business Mailing Address
First Line	:	800 W DIVERSEY PKWY # 200
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1412
Country	:	US
Telephone Number	:	312-796-7121
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 W DIVERSEY PKWY # 200
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1412
Country	:	US
Telephone Number	:	312-796-7121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2015
Last Update Date	:	09/11/2023

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