MEDICARE: MATTHEW ALEXANDER JORDAN MS, LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	0126003611	VA

General Provider Information

NPI Number	:	1215711759
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW ALEXANDER JORDAN MS, LAT, ATC

Provider Business Mailing Address
First Line	:	9682 CEDAR FARM CIR
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031-5404
Country	:	US
Telephone Number	:	571-414-7433
Fax Number	:

Provider Business Practice Location Address
First Line	:	20041 RIVERSIDE COMMONS PLZ
Second Line	:
City	:	ASHBURN
State	:	VA
Zip	:	20147-5151
Country	:	US
Telephone Number	:	703-466-0447
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2023
Last Update Date	:	08/24/2023

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