=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760691257
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN TEREZ JORDAN M.D., PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 12/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 WHITE HORSE ROAD SUITE 902 GLENDALE EXECUTIVE CAMPUS
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-4415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-309-1363
-----------------------------------------------------
Fax | 856-309-1369
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 1584
-----------------------------------------------------
City | MOUNT LAUREL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08054-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-309-1363
-----------------------------------------------------
Fax | 856-309-1369
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 25MA05031400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD039046E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------