Healthcare Provider Details

I. General information

NPI: 1861195562
Provider Name (Legal Business Name): JORDAN E LAIRD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7704 MATAPEAKE BUSINESS DR STE 110
BRANDYWINE MD
20613-3036
US

IV. Provider business mailing address

5403 STREAM BANK LN
GREENBELT MD
20770-4098
US

V. Phone/Fax

Practice location:
  • Phone: 301-242-5678
  • Fax: 410-367-2354
Mailing address:
  • Phone: 813-973-9738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1048625
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR230002
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberN118073
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR230002
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: