Provider Demographics
NPI:1942987755
Name:SMITH, JORDAN CHARLES
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:CHARLES
Last Name:SMITH
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 1:8191 STRAWBERRY LN STE 6
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1032
Mailing Address - Country:US
Mailing Address - Phone:703-493-0404
Mailing Address - Fax:
Practice Address - Street 1:8191 STRAWBERRY LN
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042
Practice Address - Country:US
Practice Address - Phone:703-493-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant