Provider Demographics
NPI:1558125179
Name:CALLAIS, JORDAN CHRISTOPHER
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:CHRISTOPHER
Last Name:CALLAIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 RALPH WILLIAMS RD
Mailing Address - Street 2:
Mailing Address - City:PROSPERITY
Mailing Address - State:SC
Mailing Address - Zip Code:29127-9015
Mailing Address - Country:US
Mailing Address - Phone:803-800-8124
Mailing Address - Fax:
Practice Address - Street 1:149 RALPH WILLIAMS RD
Practice Address - Street 2:
Practice Address - City:PROSPERITY
Practice Address - State:SC
Practice Address - Zip Code:29127-9015
Practice Address - Country:US
Practice Address - Phone:803-800-8124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-15756363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program