Provider Demographics
NPI:1821628918
Name:JORDAN, AMY ROSE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ROSE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 STANTON RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-2927
Mailing Address - Country:US
Mailing Address - Phone:757-842-1560
Mailing Address - Fax:
Practice Address - Street 1:12727 MCMANUS BLVD.
Practice Address - Street 2:SUITE G
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602
Practice Address - Country:US
Practice Address - Phone:757-877-2300
Practice Address - Fax:757-264-6258
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician