Healthcare Provider Details

I. General information

NPI: 1831520055
Provider Name (Legal Business Name): JUSTIN JORDAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2013
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 UNIVERSITY CITY BLVD
BLACKSBURG VA
24060-2706
US

IV. Provider business mailing address

700 UNIVERSITY CITY BLVD
BLACKSBURG VA
24060-2706
US

V. Phone/Fax

Practice location:
  • Phone: 540-961-8300
  • Fax: 540-443-0053
Mailing address:
  • Phone: 540-961-8300
  • Fax: 540-443-0053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701005679
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701005679
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: