Healthcare Provider Details

I. General information

NPI: 1518783984
Provider Name (Legal Business Name): EILEEN JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FALCON WAY
BOW NH
03304-4228
US

IV. Provider business mailing address

236 UPPER BAY RD
SANBORNTON NH
03269-2723
US

V. Phone/Fax

Practice location:
  • Phone: 603-228-2210
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number98605
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: