Provider Demographics
NPI:1316693047
Name:JORDAN, TIFFANY RAE (NP)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:RAE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:270 CHASTAIN RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-3012
Mailing Address - Country:US
Mailing Address - Phone:770-421-8005
Mailing Address - Fax:770-424-5662
Practice Address - Street 1:270 CHASTAIN RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-3012
Practice Address - Country:US
Practice Address - Phone:770-421-8005
Practice Address - Fax:770-424-5662
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN240185363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily