Provider Demographics
NPI:1558825174
Name:JORDAN M EDMONDSON
Entity Type:Organization
Organization Name:JORDAN M EDMONDSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGRAFTENREED
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:214-763-8584
Mailing Address - Street 1:2120 FOXGLOVE CT
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-6360
Mailing Address - Country:US
Mailing Address - Phone:214-763-8584
Mailing Address - Fax:
Practice Address - Street 1:2120 FOXGLOVE CT
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-6360
Practice Address - Country:US
Practice Address - Phone:214-763-8584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-28
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health