Provider Demographics
NPI:1063084119
Name:KAYES, JORDAN JACKSON
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:JACKSON
Last Name:KAYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:LEIGH
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2430 EMERALD PL STE 103
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5743
Mailing Address - Country:US
Mailing Address - Phone:252-752-2140
Mailing Address - Fax:
Practice Address - Street 1:2430 EMERALD PL STE 103
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5743
Practice Address - Country:US
Practice Address - Phone:252-916-2133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC294961163W00000X, 390200000X
NC6870367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program