Individual
JORDAN PHENICIE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
3555 S NATIONAL AVE, SPRINGFIELD, MO 65807-7310
(417) 875-3800
Mailing address
PO BOX 9007, SPRINGFIELD, MO 65808-9007
(417) 875-3000
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
2018003312
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
220051881
—
MO
Enumeration date
02/21/2018
Last updated
12/27/2018
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