Provider Demographics
NPI:1194211599
Name:JORDAN RIVER SUPPORT SERVICES
Entity Type:Organization
Organization Name:JORDAN RIVER SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:DESHAY
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-250-5943
Mailing Address - Street 1:2616 LANGHORNE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1600
Mailing Address - Country:US
Mailing Address - Phone:434-250-5943
Mailing Address - Fax:434-439-2933
Practice Address - Street 1:2616 LANGHORNE RD STE 1
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1600
Practice Address - Country:US
Practice Address - Phone:434-250-5943
Practice Address - Fax:434-439-2933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2864-03-001251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health