Provider Demographics
NPI:1861100950
Name:JORDAN, HEATHER NICOLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:NICOLE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:NICOLE
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 CATAMARAN LN
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-9012
Mailing Address - Country:US
Mailing Address - Phone:970-620-7057
Mailing Address - Fax:
Practice Address - Street 1:3532 MONROE ST # 6322
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-6322
Practice Address - Country:US
Practice Address - Phone:951-552-8504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007601363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant