Provider Demographics
NPI:1316788946
Name:ELAM, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:ELAM
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:PO BOX 715868
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19171-5868
Mailing Address - Country:US
Mailing Address - Phone:804-915-1910
Mailing Address - Fax:804-968-1803
Practice Address - Street 1:12216 W BROAD ST STE 4B-5
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-1062
Practice Address - Country:US
Practice Address - Phone:804-533-0071
Practice Address - Fax:804-200-7124
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305216529225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist