Provider Demographics
NPI:1215422514
Name:JORDAN, JACQUELINE (PA-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 SHERMAN LN
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-1326
Mailing Address - Country:US
Mailing Address - Phone:201-312-5863
Mailing Address - Fax:
Practice Address - Street 1:809 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3142
Practice Address - Country:US
Practice Address - Phone:860-528-1359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT23.004134363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty