Provider Demographics
NPI:1760145809
Name:HARRIS, JORDAN DRISKILL (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:DRISKILL
Last Name:HARRIS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HERON RUN DR
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2188
Mailing Address - Country:US
Mailing Address - Phone:804-691-3786
Mailing Address - Fax:
Practice Address - Street 1:5501 CONDUIT RD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2121
Practice Address - Country:US
Practice Address - Phone:804-524-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007534235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist