Provider Demographics
NPI:1275081333
Name:COLEMAN, JORDAN A (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:A
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:A
Other - Last Name:JEFFRIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:1300 E BRADFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4264
Mailing Address - Country:US
Mailing Address - Phone:417-761-5000
Mailing Address - Fax:417-761-5011
Practice Address - Street 1:1675 E SEMINOLE ST STE A1
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2454
Practice Address - Country:US
Practice Address - Phone:417-597-4309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016034046103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490035887Medicaid