Provider Demographics
NPI:1730583220
Name:JORDAN, KRISTEN MOORE (PA-C, LAT, ATC)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MOORE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PA-C, LAT, ATC
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ANNE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C, PAT, ATC
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0068
Mailing Address - Country:US
Mailing Address - Phone:252-634-2676
Mailing Address - Fax:252-637-4479
Practice Address - Street 1:738 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5238
Practice Address - Country:US
Practice Address - Phone:252-634-2676
Practice Address - Fax:252-637-4479
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19892255A2300X
NC0010-09015363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer