Provider Demographics
NPI:1053662585
Name:CHANG, JORDAN R (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:R
Last Name:CHANG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 PROGRESS ST NE
Mailing Address - Street 2:2
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-7225
Mailing Address - Country:US
Mailing Address - Phone:410-599-8405
Mailing Address - Fax:
Practice Address - Street 1:600 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-1826
Practice Address - Country:US
Practice Address - Phone:540-663-0413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207623225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist