Provider Demographics
NPI:1164264479
Name:KING, JORDON CHRISTOPHER KELSEY (MMSC)
Entity type:Individual
Prefix:
First Name:JORDON
Middle Name:CHRISTOPHER KELSEY
Last Name:KING
Suffix:
Gender:U
Credentials:MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3104 GALANGALE WAY
Mailing Address - Street 2:
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30340-4610
Mailing Address - Country:US
Mailing Address - Phone:425-870-2298
Mailing Address - Fax:
Practice Address - Street 1:3001 MERCER UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-4115
Practice Address - Country:US
Practice Address - Phone:678-547-6305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-07
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12468363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant