Provider Demographics
NPI:1104706910
Name:FIELDER, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:FIELDER
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 1:1040 VILLAS CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-6364
Mailing Address - Country:US
Mailing Address - Phone:757-575-8275
Mailing Address - Fax:877-831-7109
Practice Address - Street 1:908 SALISBURY GRN
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-6123
Practice Address - Country:US
Practice Address - Phone:757-406-7397
Practice Address - Fax:877-831-7109
Is Sole Proprietor?:No
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-25-469069106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician