Provider Demographics
NPI:1437782711
Name:CROLLE-JORDAN, ZAKKIYYA (MT)
Entity Type:Individual
Prefix:MISS
First Name:ZAKKIYYA
Middle Name:
Last Name:CROLLE-JORDAN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 LASKIN RD STE 202
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-5260
Mailing Address - Country:US
Mailing Address - Phone:732-682-9299
Mailing Address - Fax:
Practice Address - Street 1:1213 LASKIN RD STE 202
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-5260
Practice Address - Country:US
Practice Address - Phone:732-682-9299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019010003225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist