Provider Demographics
NPI:1578779336
Name:JORDAN, JANNETTA DELOIS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JANNETTA
Middle Name:DELOIS
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 SALTWELL PL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-6100
Mailing Address - Country:US
Mailing Address - Phone:910-213-4160
Mailing Address - Fax:
Practice Address - Street 1:2018 HOPE MILLS RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4225
Practice Address - Country:US
Practice Address - Phone:910-424-0972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6537101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional