Provider Demographics
NPI:1104201524
Name:JORDAN, KERA D (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KERA
Middle Name:D
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15344 ELIZABETH BURBAGE LOOP
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4146
Mailing Address - Country:US
Mailing Address - Phone:423-618-8080
Mailing Address - Fax:
Practice Address - Street 1:1 PARK WEST CIR
Practice Address - Street 2:108
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-5551
Practice Address - Country:US
Practice Address - Phone:804-379-9265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006888235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist