Provider Demographics
NPI:1326330663
Name:SIMONSON, JORDAN LEE (PHD)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:LEE
Last Name:SIMONSON
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 1:221 3RD ST W
Mailing Address - Street 2:JOINT BASE SAN ANTONIO - RANDOLPH CLINIC
Mailing Address - City:RANDOLPH AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78150-4800
Mailing Address - Country:US
Mailing Address - Phone:210-565-3898
Mailing Address - Fax:
Practice Address - Street 1:221 3RD ST W
Practice Address - Street 2:JOINT BASE SAN ANTONIO - RANDOLPH CLINIC
Practice Address - City:RANDOLPH AFB
Practice Address - State:TX
Practice Address - Zip Code:78150-4800
Practice Address - Country:US
Practice Address - Phone:210-565-3898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60504955103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical