Provider Demographics
NPI:1992292049
Name:KANTOR, JORDAN ELIZABETH
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ELIZABETH
Last Name:KANTOR
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 1:1114 4TH ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4208
Mailing Address - Country:US
Mailing Address - Phone:540-588-4897
Mailing Address - Fax:
Practice Address - Street 1:1114 4TH ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4208
Practice Address - Country:US
Practice Address - Phone:540-588-4897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1237000020246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical