MEDICARE: DEANNAH MARIE JORDAN MD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	208000000X	Pediatrics Physician	0101278658	VA

General Provider Information

NPI Number	:	1700405859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEANNAH MARIE JORDAN MD

Provider Business Mailing Address
First Line	:	8468 JANE WAY
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23503-4008
Country	:	US
Telephone Number	:	814-270-3065
Fax Number	:

Provider Business Practice Location Address
First Line	:	1529 INTERNATIONAL BLVD STE 103
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23513-4802
Country	:	US
Telephone Number	:	757-855-6800
Fax Number	:

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

Provider Enumeration Date	:	04/09/2020
Last Update Date	:	06/12/2023

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