Provider Demographics
NPI:1376096842
Name:ALLISON, JORDAN (PSYD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:ALLISON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 NORTHPARKE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-1117
Mailing Address - Country:US
Mailing Address - Phone:937-325-3696
Mailing Address - Fax:937-325-3713
Practice Address - Street 1:211 NORTHPARKE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-1117
Practice Address - Country:US
Practice Address - Phone:937-325-3696
Practice Address - Fax:937-325-3713
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7469103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical