Provider Demographics
NPI:1821519737
Name:JORDAN, THOMAS ROGER
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ROGER
Last Name:JORDAN
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 1:11 RIDGE RD UNIT C
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2949
Mailing Address - Country:US
Mailing Address - Phone:301-474-0067
Mailing Address - Fax:202-204-5849
Practice Address - Street 1:4907 NIAGARA RD STE 102
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-1100
Practice Address - Country:US
Practice Address - Phone:301-474-0067
Practice Address - Fax:202-204-5849
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR02499225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist