Provider Demographics
NPI:1124552708
Name:BACKSTROM, JORDAN PAUL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:PAUL
Last Name:BACKSTROM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1105
Mailing Address - Country:US
Mailing Address - Phone:781-895-7963
Mailing Address - Fax:
Practice Address - Street 1:85 1ST AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1105
Practice Address - Country:US
Practice Address - Phone:781-895-7963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10520103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical