Provider Demographics
NPI:1972079846
Name:JORDAN, JEREMIAH
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
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 1:8094 SPOTSWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:STANARDSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22973-2846
Mailing Address - Country:US
Mailing Address - Phone:434-939-9001
Mailing Address - Fax:
Practice Address - Street 1:8094 SPOTSWOOD TRL
Practice Address - Street 2:
Practice Address - City:STANARDSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22973-2846
Practice Address - Country:US
Practice Address - Phone:434-939-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0813000755Medicaid