Provider Demographics
NPI:1831630227
Name:DOUGHTY, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:DOUGHTY
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 1:20410 CENTURY BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-1186
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18109 PRINCE PHILIP DR
Practice Address - Street 2:SUITE B-200
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1519
Practice Address - Country:US
Practice Address - Phone:855-546-2066
Practice Address - Fax:301-570-7416
Is Sole Proprietor?:No
Enumeration Date:2017-03-17
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPTA1983225200000X
MDA4729225200000X
WAP161429707225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant