Provider Demographics
NPI:1972267797
Name:TAYLOR, JORDAN ARENEAL
Entity type:Individual
Prefix:MS
First Name:JORDAN
Middle Name:ARENEAL
Last Name:TAYLOR
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 1:1111 76TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23605-1703
Mailing Address - Country:US
Mailing Address - Phone:757-768-3218
Mailing Address - Fax:
Practice Address - Street 1:293 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5466
Practice Address - Country:US
Practice Address - Phone:757-490-3009
Practice Address - Fax:877-799-3228
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VABACB712342106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician