Provider Demographics
NPI:1205457553
Name:MASTERS, JORDAN TAYLOR (MSW, LGSW)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:TAYLOR
Last Name:MASTERS
Suffix:
Gender:F
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 BEVERLY RD STE 320
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3648
Mailing Address - Country:US
Mailing Address - Phone:703-556-6655
Mailing Address - Fax:
Practice Address - Street 1:1355 BEVERLY RD STE 320
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3648
Practice Address - Country:US
Practice Address - Phone:703-556-6655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG50083247104100000X
VA0906009777104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0906009777OtherSUPERVISEE IN CLINICAL SOCIAL WORK
DCLG50083247OtherLGSW