Provider Demographics
NPI:1700507274
Name:RALSTON, JORDAN KELLER (NP)
Entity Type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:KELLER
Last Name:RALSTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 780125
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0125
Mailing Address - Country:US
Mailing Address - Phone:804-828-8647
Mailing Address - Fax:804-828-8765
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5023
Practice Address - Country:US
Practice Address - Phone:804-628-4327
Practice Address - Fax:804-828-8321
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024184933363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner