Provider Demographics
NPI:1861195562
Name:LAIRD, JORDAN E
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:E
Last Name:LAIRD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5403 STREAM BANK LN
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-4098
Mailing Address - Country:US
Mailing Address - Phone:813-973-9738
Mailing Address - Fax:
Practice Address - Street 1:7704 MATAPEAKE BUSINESS DR STE 110
Practice Address - Street 2:
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-3036
Practice Address - Country:US
Practice Address - Phone:301-242-5678
Practice Address - Fax:410-367-2354
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1048625163W00000X
MDR230002163W00000X, 363L00000X
MDN118073363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse