Provider Demographics
NPI:1093267528
Name:JORDAN, DIANE MAXINE (LPCA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MAXINE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 OAKCREST PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-1127
Mailing Address - Country:US
Mailing Address - Phone:704-309-5107
Mailing Address - Fax:
Practice Address - Street 1:2704 OAKCREST PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-1127
Practice Address - Country:US
Practice Address - Phone:704-309-5107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12587101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health