Provider Demographics
NPI:1235296377
Name:JORDAN, JOHN ROBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:JORDAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 EXCHANGE CT
Mailing Address - Street 2:UNIT 401
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-2261
Mailing Address - Country:US
Mailing Address - Phone:401-305-3051
Mailing Address - Fax:401-305-3051
Practice Address - Street 1:10 EXCHANGE CT
Practice Address - Street 2:UNIT 401
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-2261
Practice Address - Country:US
Practice Address - Phone:401-305-3051
Practice Address - Fax:401-305-3051
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1936103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW02078Medicare ID - Type UnspecifiedMEDICARE-BC-BS NUMBER