Provider Demographics
NPI:1114344223
Name:HARVEY, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:HARVEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 DANIELS ST
Mailing Address - Street 2:
Mailing Address - City:HEALDTON
Mailing Address - State:OK
Mailing Address - Zip Code:73438-1417
Mailing Address - Country:US
Mailing Address - Phone:580-264-0122
Mailing Address - Fax:
Practice Address - Street 1:174 DANIELS ST
Practice Address - Street 2:
Practice Address - City:HEALDTON
Practice Address - State:OK
Practice Address - Zip Code:73438-1417
Practice Address - Country:US
Practice Address - Phone:580-264-0122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKP082823145103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation