Provider Demographics
NPI:1801386735
Name:LEE, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 DAVIS ST STE B
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-7009
Mailing Address - Country:US
Mailing Address - Phone:540-352-4304
Mailing Address - Fax:504-591-7340
Practice Address - Street 1:65 SHENANDOAH AVE STE 203
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24083-3205
Practice Address - Country:US
Practice Address - Phone:540-352-4304
Practice Address - Fax:540-591-7340
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211889225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist