Provider Demographics
NPI:1013211390
Name:JORDAN, KAREN DIANE (MED)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:DIANE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 TWELVE OAKS CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-1467
Mailing Address - Country:US
Mailing Address - Phone:940-631-5666
Mailing Address - Fax:940-692-9722
Practice Address - Street 1:4245 KEMP BLVD
Practice Address - Street 2:SUITE 710
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2824
Practice Address - Country:US
Practice Address - Phone:940-692-9745
Practice Address - Fax:940-692-9722
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-31
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64906101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional