Provider Demographics
NPI:1205851995
Name:JORDAN, TRACI L (PSYD, LSSP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PSYD, LSSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7118 SPICE LEAF TRL
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-2010
Mailing Address - Country:US
Mailing Address - Phone:361-232-0013
Mailing Address - Fax:
Practice Address - Street 1:1210 FOURIER DR STE 100
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1969
Practice Address - Country:US
Practice Address - Phone:608-662-9327
Practice Address - Fax:608-662-9041
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ005597103T00000X
CO0006061103T00000X
TX24625103TC0700X
TX30404103TS0200X
WI5154103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX031190402Medicaid
TX0081AWMedicare ID - Type Unspecified