Provider Demographics
NPI:1205337359
Name:JORDAN, DEBORAH MICHELLE
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:MICHELLE
Last Name:JORDAN
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 1:2533 COTTON PATCH RD
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:VA
Mailing Address - Zip Code:24557-2496
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2533 COTTON PATCH RD
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:VA
Practice Address - Zip Code:24557-2496
Practice Address - Country:US
Practice Address - Phone:434-429-5699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60209323347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle