Provider Demographics
NPI:1982363313
Name:JOHNSON, JORDYN (PA-C)
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:
Last Name:JOHNSON
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 1:30960 STAGECOACH BLVD # 120
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7902
Mailing Address - Country:US
Mailing Address - Phone:303-674-6671
Mailing Address - Fax:
Practice Address - Street 1:30960 STAGECOACH BLVD # 120
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7902
Practice Address - Country:US
Practice Address - Phone:303-674-6671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA0008139363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant