Provider Demographics
NPI:1104976935
Name:JORDAN, ANTWAN L (DC)
Entity type:Individual
Prefix:DR
First Name:ANTWAN
Middle Name:L
Last Name:JORDAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 OLD GEORGE WASHINGTON HWY N
Mailing Address - Street 2:SUITE E
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23323-2209
Mailing Address - Country:US
Mailing Address - Phone:757-485-5666
Mailing Address - Fax:757-485-8666
Practice Address - Street 1:838 OLD GEORGE WASHINGTON HWY N
Practice Address - Street 2:SUITE E
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23323-2209
Practice Address - Country:US
Practice Address - Phone:757-485-5666
Practice Address - Fax:757-485-8666
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556244111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAV00882Medicare UPIN
VA00W523C12Medicare ID - Type UnspecifiedINDIVIDUAL