Provider Demographics
NPI:1265951610
Name:WILSON, JORDAN ELISABETH
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ELISABETH
Last Name:WILSON
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 1:1114 MAIN ST APT A
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-2954
Mailing Address - Country:US
Mailing Address - Phone:434-709-7107
Mailing Address - Fax:
Practice Address - Street 1:1114 MAIN ST APT A
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-2954
Practice Address - Country:US
Practice Address - Phone:434-709-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-15-05000106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician