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General NPI Number Information
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NPI Number | 1215711759
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Entity Type | Individual
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Provider Name | MATTHEW ALEXANDER JORDAN MS, LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 08/24/2023
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Last Update Date | 08/24/2023
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Provider Practice Location Address
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Address Line | 20041 RIVERSIDE COMMONS PLZ
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City | ASHBURN
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State | VA
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Zip | 20147-5151
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Country | US
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Telephone | 703-466-0447
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Fax |
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Provider Business Mailing Address
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Address Line | 9682 CEDAR FARM CIR
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City | FAIRFAX
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State | VA
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Zip | 22031-5404
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Country | US
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Telephone | 571-414-7433
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 0126003611
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License Number State | VA
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