Provider Demographics
NPI:1114310513
Name:BOYD, JORDAN ALEXANDER
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ALEXANDER
Last Name:BOYD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 W ILLINOIS ST APT 1
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-7921
Mailing Address - Country:US
Mailing Address - Phone:708-341-8713
Mailing Address - Fax:
Practice Address - Street 1:1801 FOX DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7236
Practice Address - Country:US
Practice Address - Phone:217-398-8464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor