Provider Demographics
NPI:1861952376
Name:PHELPS, JORDAN MICAH (DO)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MICAH
Last Name:PHELPS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:705 WELLS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2982
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:904-619-1080
Practice Address - Street 1:14011 BEACH BLVD STE 120
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-1695
Practice Address - Country:US
Practice Address - Phone:904-223-6400
Practice Address - Fax:833-578-1820
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS19877207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine