Provider Demographics
NPI:1124836911
Name:DODSON, JORDAN DAVID
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:DAVID
Last Name:DODSON
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 1:4801 KENMORE AVE APT 521
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1108
Mailing Address - Country:US
Mailing Address - Phone:443-602-2213
Mailing Address - Fax:
Practice Address - Street 1:4801 KENMORE AVE APT 521
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1108
Practice Address - Country:US
Practice Address - Phone:443-602-2213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-25
Last Update Date:2024-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119010598225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist