Provider Demographics
NPI:1275623357
Name:JORDAN, KRISTA DIANE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:DIANE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4534 W GATE BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1485
Mailing Address - Country:US
Mailing Address - Phone:512-439-7360
Mailing Address - Fax:512-439-7371
Practice Address - Street 1:4534 W GATE BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1485
Practice Address - Country:US
Practice Address - Phone:512-439-7360
Practice Address - Fax:512-439-7371
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26883103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical