Provider Demographics
NPI:1306697529
Name:ROGERS, JORDAN WESLEY (PA)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:WESLEY
Last Name:ROGERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3286 EAGLE WATCH DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-6854
Mailing Address - Country:US
Mailing Address - Phone:770-789-8742
Mailing Address - Fax:
Practice Address - Street 1:275 COLLIER RD NW STE 300
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1740
Practice Address - Country:US
Practice Address - Phone:404-350-0009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant