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General NPI Number Information
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NPI Number | 1154728566
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Entity Type | Organization
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Legal Business Name | MANDY JORDAN PH.D.
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Dates
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Enumeration Date | 12/01/2014
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Last Update Date | 12/01/2014
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Provider Practice Location Address
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Address Line | 3509 HULEN ST STE 107
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City | FORT WORTH
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State | TX
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Zip | 76107-6800
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Country | US
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Telephone | 817-916-8200
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Fax |
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Provider Business Mailing Address
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Address Line | 3509 HULEN ST STE 107
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City | FORT WORTH
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State | TX
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Zip | 76107-6800
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Country | US
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Telephone | 817-916-8200
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. MANDY JO JORDAN
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Credential | PH.D.
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Telephone | 817-916-8200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 34438
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License Number State | TX
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