Provider Demographics
NPI:1255013298
Name:O'MALLEY, JORDAN (PA-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 W INNOVATION DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4851
Mailing Address - Country:US
Mailing Address - Phone:888-938-3838
Mailing Address - Fax:888-919-1083
Practice Address - Street 1:8401 SEASONS PKWY STE 300
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3476
Practice Address - Country:US
Practice Address - Phone:888-938-3838
Practice Address - Fax:888-919-1083
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15374363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant