Provider Demographics
NPI:1154190767
Name:TANAVAGE, JORDAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:TANAVAGE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 296
Mailing Address - Street 2:
Mailing Address - City:CHAPTICO
Mailing Address - State:MD
Mailing Address - Zip Code:20621-0296
Mailing Address - Country:US
Mailing Address - Phone:240-577-8351
Mailing Address - Fax:
Practice Address - Street 1:2222 COLTS NECK RD
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-2843
Practice Address - Country:US
Practice Address - Phone:703-429-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-22
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305215372225100000X
MD30263225100000X
DCCP039578T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist