Provider Demographics
NPI:1801327812
Name:JORDAN, PHILLIP
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6379 CENTER DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4102
Mailing Address - Country:US
Mailing Address - Phone:757-388-3397
Mailing Address - Fax:757-388-2885
Practice Address - Street 1:600 GRESHAM DR
Practice Address - Street 2:RALEIGH BUILDING, SUITE 304
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-3397
Practice Address - Fax:757-388-2885
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101269116207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program