Provider Demographics
NPI:1699158626
Name:PERRY, JORDAN L (PA-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:L
Last Name:PERRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:L
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3200 E RACINE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2343
Mailing Address - Country:US
Mailing Address - Phone:608-371-8000
Mailing Address - Fax:608-371-8945
Practice Address - Street 1:3200 E RACINE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-2343
Practice Address - Country:US
Practice Address - Phone:608-371-8000
Practice Address - Fax:608-371-8945
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3581-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1699158626Medicaid
WIP01516156OtherRAILROAD MEDICARE
WIP01516156OtherRAILROAD MEDICARE