Healthcare Provider Details

I. General information

NPI: 1750507372
Provider Name (Legal Business Name): JORDAN BAILEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3908 OLD BUCKINGHAM RD
POWHATAN VA
23139-5753
US

IV. Provider business mailing address

2410 PAGEHURST DR
MIDLOTHIAN VA
23113-6411
US

V. Phone/Fax

Practice location:
  • Phone: 804-598-5637
  • Fax:
Mailing address:
  • Phone: 804-897-6140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024167210
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: