Healthcare Provider Details

I. General information

NPI: 1740920503
Provider Name (Legal Business Name): JORDYN NICOLE SEWELL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 OLD BRICK RD
GLEN ALLEN VA
23060-5837
US

IV. Provider business mailing address

4851 GARDEN SPRING LN APT 207
GLEN ALLEN VA
23059-7505
US

V. Phone/Fax

Practice location:
  • Phone: 812-698-7095
  • Fax:
Mailing address:
  • Phone: 812-698-7095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: