Provider Demographics
NPI:1265646608
Name:JORDAN, JOHANNA (MA)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 LEE RD
Mailing Address - Street 2:SUITE 23
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-1864
Mailing Address - Country:US
Mailing Address - Phone:407-628-8494
Mailing Address - Fax:407-628-8219
Practice Address - Street 1:2221 LEE RD
Practice Address - Street 2:SUITE 23
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-1864
Practice Address - Country:US
Practice Address - Phone:407-628-8494
Practice Address - Fax:407-628-8219
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT1204106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist