Provider Demographics
NPI:1174282453
Name:JORDAN, KRYSTLE (MFT)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 IVORY RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2607
Mailing Address - Country:US
Mailing Address - Phone:860-728-8245
Mailing Address - Fax:
Practice Address - Street 1:37 CAMP MOWEEN RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:CT
Practice Address - Zip Code:06249-2704
Practice Address - Country:US
Practice Address - Phone:860-889-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT18036417101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor