Provider Demographics
NPI:1457472433
Name:JORDAN, LAJUANA B (GNP)
Entity Type:Individual
Prefix:MS
First Name:LAJUANA
Middle Name:B
Last Name:JORDAN
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-4070
Mailing Address - Country:US
Mailing Address - Phone:434-251-6793
Mailing Address - Fax:434-791-2824
Practice Address - Street 1:130 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-4070
Practice Address - Country:US
Practice Address - Phone:434-791-2273
Practice Address - Fax:434-791-2824
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167202207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024167202OtherSTATE LICENSE NUMBER
VA013382P78Medicare PIN
VA1248110001Medicare NSC