Healthcare Provider Details

I. General information

NPI: 1265446215
Provider Name (Legal Business Name): CHRISTINE J JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 HOLLY AVE
WINSTON SALEM NC
27101-2716
US

IV. Provider business mailing address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

V. Phone/Fax

Practice location:
  • Phone: 336-725-3999
  • Fax:
Mailing address:
  • Phone: 336-716-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number3945
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number978
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: