Healthcare Provider Details

I. General information

NPI: 1417878158
Provider Name (Legal Business Name): JORDYN WIESBOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 TOWN CENTER DR
RESTON VA
20190-5896
US

IV. Provider business mailing address

9875 RAINLEAF CT
BRISTOW VA
20136-2416
US

V. Phone/Fax

Practice location:
  • Phone: 571-201-8238
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001260643
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: