Healthcare Provider Details

I. General information

NPI: 1497662324
Provider Name (Legal Business Name): KATLYN JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5780 TROY RD
SPRINGFIELD OH
45502-8131
US

IV. Provider business mailing address

898 MARIDON CT
VANDALIA OH
45377-3040
US

V. Phone/Fax

Practice location:
  • Phone: 937-964-1324
  • Fax:
Mailing address:
  • Phone: 937-974-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLSP.03212
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: