Provider Demographics
NPI:1669943536
Name:MCDOUGAL, JORDAN WADE (RBT)
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:WADE
Last Name:MCDOUGAL
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 JIB DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-5322
Mailing Address - Country:US
Mailing Address - Phone:540-699-4922
Mailing Address - Fax:
Practice Address - Street 1:1411 PRINCESS ANNE STREET
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401
Practice Address - Country:US
Practice Address - Phone:540-922-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician