Healthcare Provider Details

I. General information

NPI: 1477561447
Provider Name (Legal Business Name): ROBERT JOHN JORDAN MASSAGE THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6810 TILDEN LN
ROCKVILLE MD
20852-4501
US

IV. Provider business mailing address

6810 TILDEN LN
ROCKVILLE MD
20852-4501
US

V. Phone/Fax

Practice location:
  • Phone: 301-468-3962
  • Fax: 301-984-0218
Mailing address:
  • Phone: 301-468-3962
  • Fax: 301-984-0218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberM02335
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: