Provider Demographics
NPI:1457315947
Name:JORDAN, KIMBERLY ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ELIZABETH
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LAKE HEARN DR STE 450
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1524
Mailing Address - Country:US
Mailing Address - Phone:404-365-0966
Mailing Address - Fax:
Practice Address - Street 1:1100 LAKE HEARN DR STE 450
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1524
Practice Address - Country:US
Practice Address - Phone:404-365-0966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA105060207Q00000X
OH35-08-3111-J207Q00000X
NC2010-01703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2522569Medicaid
NC2010-01703OtherNC MEDICAL LICENSE
OH4147044Medicare PIN
OHI21404Medicare UPIN
OH2522569Medicaid
OH4147045Medicare PIN
OH4147041Medicare PIN