Provider Demographics
NPI:1164027991
Name:KITCHENS, JORDAN LOUIS
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LOUIS
Last Name:KITCHENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-2911
Mailing Address - Country:US
Mailing Address - Phone:757-385-4789
Mailing Address - Fax:
Practice Address - Street 1:297 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-2911
Practice Address - Country:US
Practice Address - Phone:757-385-4789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040168561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid