Provider Demographics
NPI:1639362809
Name:JORDAN, AVERY MILES (LPTA/LPN)
Entity Type:Individual
Prefix:MR
First Name:AVERY
Middle Name:MILES
Last Name:JORDAN
Suffix:
Gender:M
Credentials:LPTA/LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:3708 STAMFORD CIR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3671
Mailing Address - Country:US
Mailing Address - Phone:804-744-5303
Mailing Address - Fax:
Practice Address - Street 1:1201 E BROAD ROCK RD
Practice Address - Street 2:RM 1S-112
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23249-0001
Practice Address - Country:US
Practice Address - Phone:804-675-5000
Practice Address - Fax:804-675-5335
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002040749164W00000X
VA2306001152225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No164W00000XNursing Service ProvidersLicensed Practical Nurse