Provider Demographics
NPI:1679934400
Name:KING, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:KING
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 1:2728 W MALLARD CREEK CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-2308
Mailing Address - Country:US
Mailing Address - Phone:980-218-1860
Mailing Address - Fax:
Practice Address - Street 1:2728 W MALLARD CREEK CHURCH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-2308
Practice Address - Country:US
Practice Address - Phone:980-218-1860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2024-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant