Provider Demographics
NPI:1962007096
Name:JORDAN, PHYLLIS V (LMT, RMP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:V
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LMT, RMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 E A ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:MD
Mailing Address - Zip Code:21716-1473
Mailing Address - Country:US
Mailing Address - Phone:240-578-5958
Mailing Address - Fax:
Practice Address - Street 1:263 W PATRICK ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-6910
Practice Address - Country:US
Practice Address - Phone:301-388-5237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019015415225700000X
MDR02519225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist