Healthcare Provider Details

I. General information

NPI: 1851104582
Provider Name (Legal Business Name): JORDAN THOMAS PARKER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2025
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 CORPORATION LN
VIRGINIA BEACH VA
23462-3262
US

IV. Provider business mailing address

2900 EVERGREEN CT
CHESAPEAKE VA
23321-4209
US

V. Phone/Fax

Practice location:
  • Phone: 757-233-0003
  • Fax:
Mailing address:
  • Phone: 757-572-4780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701014455
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: