Provider Demographics
NPI:1417798489
Name:DECKER, JORDAN G (MD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:G
Last Name:DECKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 ASHLEY AVE
Mailing Address - Street 2:ROOM 202 MAIN HOSPITAL MSC 333
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-8905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:650 ELLIS OAK DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-3089
Practice Address - Country:US
Practice Address - Phone:843-792-3451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL922262085R0202X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology