Provider Demographics
NPI:1063660207
Name:JUDITH V JORDAN,PH.D.,PC
Entity Type:Organization
Organization Name:JUDITH V JORDAN,PH.D.,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:VICTORIA
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:617-855-2140
Mailing Address - Street 1:114 WALTHAM ST
Mailing Address - Street 2:SUITE 17
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-5415
Mailing Address - Country:US
Mailing Address - Phone:617-855-2140
Mailing Address - Fax:781-860-9592
Practice Address - Street 1:114 WALTHAM ST
Practice Address - Street 2:SUITE 17
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-5415
Practice Address - Country:US
Practice Address - Phone:617-855-2140
Practice Address - Fax:781-860-9592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1019103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW10450OtherBLUE CROSS BLUE SHIELD