Provider Demographics
NPI:1558857045
Name:JORDAN, TENEISHA SHAVAUGH (MD)
Entity type:Individual
Prefix:
First Name:TENEISHA
Middle Name:SHAVAUGH
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:177 CAROLETON DR
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-0310
Mailing Address - Country:US
Mailing Address - Phone:678-435-7764
Mailing Address - Fax:
Practice Address - Street 1:300 E HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FORT EISENHOWER
Practice Address - State:GA
Practice Address - Zip Code:30905-5741
Practice Address - Country:US
Practice Address - Phone:706-787-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-08
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA84336207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA84336OtherGEORGIA MEDICAL LICENSE