Healthcare Provider Details

I. General information

NPI: 1215711759
Provider Name (Legal Business Name): MATTHEW ALEXANDER JORDAN MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 08/24/2023
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20041 RIVERSIDE COMMONS PLZ
ASHBURN VA
20147-5151
US

IV. Provider business mailing address

9682 CEDAR FARM CIR
FAIRFAX VA
22031-5404
US

V. Phone/Fax

Practice location:
  • Phone: 703-466-0447
  • Fax:
Mailing address:
  • Phone: 571-414-7433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126003611
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: