Provider Demographics
NPI:1083745905
Name:JORDAN, THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:574 W END AVE
Mailing Address - Street 2:#64
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-2748
Mailing Address - Country:US
Mailing Address - Phone:212-875-0154
Mailing Address - Fax:212-875-0022
Practice Address - Street 1:574 W END AVE
Practice Address - Street 2:#64
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-2748
Practice Address - Country:US
Practice Address - Phone:212-875-0154
Practice Address - Fax:212-875-0022
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009162103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical