Provider Demographics
NPI:1104528918
Name:JORDAN, ANITA
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:JORDAN
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 1:181 BLACK GUM RD
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:VA
Mailing Address - Zip Code:23181-3915
Mailing Address - Country:US
Mailing Address - Phone:804-366-2604
Mailing Address - Fax:
Practice Address - Street 1:181 BLACK GUM RD
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:VA
Practice Address - Zip Code:23181-3915
Practice Address - Country:US
Practice Address - Phone:804-366-2604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119002925225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist