Provider Demographics
NPI:1528022688
Name:JORDAN, KHADIJAH YASIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KHADIJAH
Middle Name:YASIN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 MEDICAL PKWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-0302
Mailing Address - Country:US
Mailing Address - Phone:757-436-2424
Mailing Address - Fax:757-436-6628
Practice Address - Street 1:111 MEDICAL PKWY
Practice Address - Street 2:SUITE 202
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-0302
Practice Address - Country:US
Practice Address - Phone:757-436-2424
Practice Address - Fax:757-436-6628
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052592207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10202531Medicaid
VAG13925Medicare UPIN
VA10202531Medicaid