Provider Demographics
NPI:1013778984
Name:TRUSSELL, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:TRUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6720 CIRCLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BOONES MILL
Mailing Address - State:VA
Mailing Address - Zip Code:24065-2122
Mailing Address - Country:US
Mailing Address - Phone:540-776-2858
Mailing Address - Fax:
Practice Address - Street 1:520 GREEN LEVEL RD
Practice Address - Street 2:
Practice Address - City:BOONES MILL
Practice Address - State:VA
Practice Address - Zip Code:24065-3996
Practice Address - Country:US
Practice Address - Phone:540-776-2858
Practice Address - Fax:540-566-3056
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040151901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical