Provider Demographics
NPI:1568201572
Name:JORDAN, KATRINA MICHELLE (NP)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:MICHELLE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:MICHELLE
Other - Last Name:LEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:9370 HOPEWELL RD
Mailing Address - Street 2:
Mailing Address - City:LIZELLA
Mailing Address - State:GA
Mailing Address - Zip Code:31052-3830
Mailing Address - Country:US
Mailing Address - Phone:478-972-1750
Mailing Address - Fax:
Practice Address - Street 1:5398 THOMASTON RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31220-8110
Practice Address - Country:US
Practice Address - Phone:478-743-8316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN180122363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology