Provider Demographics
NPI:1861511438
Name:JORDAN, SUSAN BETH (MA)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:BETH
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 493
Mailing Address - Street 2:
Mailing Address - City:KESWICK
Mailing Address - State:VA
Mailing Address - Zip Code:22947-0493
Mailing Address - Country:US
Mailing Address - Phone:619-602-0965
Mailing Address - Fax:
Practice Address - Street 1:210 CAMPBELL RD
Practice Address - Street 2:
Practice Address - City:KESWICK
Practice Address - State:VA
Practice Address - Zip Code:22947-2109
Practice Address - Country:US
Practice Address - Phone:619-602-0965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2023-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133002601103K00000X
251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No251C00000XAgenciesDay Training, Developmentally Disabled Services