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General NPI Number Information
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NPI Number | 1740374461
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Entity Type | Individual
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Provider Name | MARK JORDAN PSY.D.
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Gender | Male
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2701 W 68TH STREET
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City | CHICAGO
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State | IL
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Zip | 60629
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Country | US
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Telephone | 708-991-9002
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Fax | 908-991-9003
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Provider Business Mailing Address
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Address Line | 162 S NORMANDY
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City | CHICAGO HEIGHTS
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State | IL
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Zip | 60411
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Country | US
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Telephone | 630-218-4369
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 71005770
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License Number State | IL
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