Provider Demographics
NPI:1669191219
Name:JORDAN, KARIDA C (ATC, LMT)
Entity type:Individual
Prefix:
First Name:KARIDA
Middle Name:C
Last Name:JORDAN
Suffix:
Gender:F
Credentials:ATC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3704 PROSPERITY AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3325
Mailing Address - Country:US
Mailing Address - Phone:571-286-6292
Mailing Address - Fax:
Practice Address - Street 1:3704 PROSPERITY AVE
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-3325
Practice Address - Country:US
Practice Address - Phone:571-286-6292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
VA0019015158225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer