Provider Demographics
NPI:1013628155
Name:SIMMONS, JORDAN L (RPRS)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:L
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:RPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3845 REDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294-6140
Mailing Address - Country:US
Mailing Address - Phone:804-240-2388
Mailing Address - Fax:
Practice Address - Street 1:4906 RADFORD AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-3512
Practice Address - Country:US
Practice Address - Phone:804-354-5532
Practice Address - Fax:804-354-5516
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0735000624175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist