Provider Demographics
NPI:1376826347
Name:MANGOLD, JORDAN M (MS CCC/SLP)
Entity Type:Individual
Prefix:MISS
First Name:JORDAN
Middle Name:M
Last Name:MANGOLD
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 MIDDLESEX RD
Mailing Address - Street 2:
Mailing Address - City:EAST GREENBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12061-2517
Mailing Address - Country:US
Mailing Address - Phone:518-929-8385
Mailing Address - Fax:
Practice Address - Street 1:50 WOODBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:NY
Practice Address - Zip Code:12037-1317
Practice Address - Country:US
Practice Address - Phone:518-392-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022494-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist