Provider Demographics
NPI:1194371195
Name:DIFFERDING, JORDAN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:DIFFERDING
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6569 N CHARLES ST STE 402
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204-5814
Mailing Address - Country:US
Mailing Address - Phone:443-849-2087
Mailing Address - Fax:443-849-8534
Practice Address - Street 1:6569 N CHARLES ST STE 402
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-5814
Practice Address - Country:US
Practice Address - Phone:443-849-2087
Practice Address - Fax:443-849-8534
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08109235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist