Provider Demographics
NPI:1649537143
Name:DESRUISSEAUX, JORDAN KIMBERLY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:KIMBERLY
Last Name:DESRUISSEAUX
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 1:809 E MARION AVE
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-3819
Mailing Address - Country:US
Mailing Address - Phone:941-637-2529
Mailing Address - Fax:941-637-2579
Practice Address - Street 1:809 E MARION AVE
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3819
Practice Address - Country:US
Practice Address - Phone:941-639-3131
Practice Address - Fax:941-637-2579
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106527363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant