Provider Demographics
NPI:1235285420
Name:JORDAN, KRISTINA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 LITTLE EAST NECK RD S
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-3208
Mailing Address - Country:US
Mailing Address - Phone:631-288-1939
Mailing Address - Fax:
Practice Address - Street 1:30 LITTLE EAST NECK RD S
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-3208
Practice Address - Country:US
Practice Address - Phone:631-288-1939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013357-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY013357-1OtherNEW YORK STATE LICENSE