Provider Demographics
NPI:1164121521
Name:JORDAN, MARY ELLEN
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 BROWNSHIRE TRL
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-5286
Mailing Address - Country:US
Mailing Address - Phone:757-447-0883
Mailing Address - Fax:757-792-8438
Practice Address - Street 1:1464 MOUNT PLEASANT RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-4043
Practice Address - Country:US
Practice Address - Phone:757-447-0883
Practice Address - Fax:757-792-8438
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician