Provider Demographics
NPI:1548972409
Name:BLYTHE, JORDAN (PA-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BLYTHE
Suffix:
Gender:M
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 1:4196 HIGHWAY 62 412 STE A
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:AR
Mailing Address - Zip Code:72542-8002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:451 PHILLIPS ST
Practice Address - Street 2:
Practice Address - City:WEST FORK
Practice Address - State:AR
Practice Address - Zip Code:72774-2813
Practice Address - Country:US
Practice Address - Phone:479-294-6085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant