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General NPI Number Information
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NPI Number | 1821519737
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Entity Type | Individual
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Provider Name | THOMAS ROGER JORDAN
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Gender | Male
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Dates
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Enumeration Date | 06/30/2017
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Last Update Date | 06/30/2017
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Provider Practice Location Address
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Address Line | 4907 NIAGARA RD STE 102
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City | COLLEGE PARK
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State | MD
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Zip | 20740-1100
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Country | US
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Telephone | 301-474-0067
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Fax | 202-204-5849
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Provider Business Mailing Address
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Address Line | 11 RIDGE RD UNIT C
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City | GREENBELT
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State | MD
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Zip | 20770-2949
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Country | US
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Telephone | 301-474-0067
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Fax | 202-204-5849
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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 | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | R02499
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License Number State | MD
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