Provider Demographics
NPI:1801318043
Name:JORDAN, MICHAEL K (DPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:JORDAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 MARTHA CUSTIS DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-2025
Mailing Address - Country:US
Mailing Address - Phone:574-360-4996
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:1308 MARTHA CUSTIS DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-2025
Practice Address - Country:US
Practice Address - Phone:574-360-4996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022222225100000X
VA23052115492251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist