Provider Demographics
NPI:1861170458
Name:TRUBY, JORDAN LANE
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LANE
Last Name:TRUBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CELEBRATE LIFE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265
Mailing Address - Country:US
Mailing Address - Phone:770-744-4809
Mailing Address - Fax:
Practice Address - Street 1:600 CELEBRATE LIFE PKWY
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-8001
Practice Address - Country:US
Practice Address - Phone:770-744-4809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX924764163W00000X
GA145632367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse