Provider Demographics
NPI:1699322115
Name:GORRELL, JORDAN LYNN (MMS, PA-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LYNN
Last Name:GORRELL
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2036 N HUMBOLDT BLVD APT 3E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3847
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 E HURON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:312-926-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007165363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant