Healthcare Provider Details

I. General information

NPI: 1063299659
Provider Name (Legal Business Name): JORDAN RUDAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11350 RANDOM HILLS RD STE 800
FAIRFAX VA
22030-6044
US

IV. Provider business mailing address

2000 TOWER OAKS BLVD
ROCKVILLE MD
20852-4282
US

V. Phone/Fax

Practice location:
  • Phone: 301-444-5001
  • Fax:
Mailing address:
  • Phone: 301-444-5001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: