Healthcare Provider Details

I. General information

NPI: 1700226321
Provider Name (Legal Business Name): THEODUS J JORDAN REVEREND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 CENTRE STREET 300840 --MAILING
JAMAICA PLAIN MA
02130-0000
US

IV. Provider business mailing address

P.O.BOX 840 804 CENTRE STREET
JAMAICA PLAIN MA
02130-0000
US

V. Phone/Fax

Practice location:
  • Phone: 508-588-6443
  • Fax: 508-588-6443
Mailing address:
  • Phone: 617-780-4323
  • Fax: 508-588-6443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: