Basic Information
| Provider Information | |||||||||
| NPI: | 1831642875 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ASHFORD | ||||||||
| FirstName: | JORDAN | ||||||||
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| OtherLastName: | DANIELL | ||||||||
| OtherFirstName: | JORDAN | ||||||||
| OtherMiddleName: | K | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 2089 TERON TRCE STE 200 | ||||||||
| Address2: | |||||||||
| City: | DACULA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300191609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709625040 | ||||||||
| FaxNumber: | 4702383078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2016 | ||||||||
| LastUpdateDate: | 05/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 008022 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.