Healthcare Provider Details

I. General information

NPI: 1942174883
Provider Name (Legal Business Name): JORDAN ALEXANDER BAILEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2025
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 BUTLER AVE
MARTINSBURG WV
25405-9991
US

IV. Provider business mailing address

826 N MARKET ST
FREDERICK MD
21701-4609
US

V. Phone/Fax

Practice location:
  • Phone: 800-817-3807
  • Fax:
Mailing address:
  • Phone: 304-741-0831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberBP00941014
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: