Provider Demographics
NPI:1578073821
Name:WILSON, JORDAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3335
Mailing Address - Country:US
Mailing Address - Phone:757-784-2454
Mailing Address - Fax:
Practice Address - Street 1:8140 ASHTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109
Practice Address - Country:US
Practice Address - Phone:703-330-9933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-01
Last Update Date:2017-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005701103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical