Provider Demographics
NPI:1609490234
Name:HARRISON, JORDAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:HARRISON
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 1:220 OLD CEDARFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6419
Mailing Address - Country:US
Mailing Address - Phone:513-702-6688
Mailing Address - Fax:
Practice Address - Street 1:2395 OAK VALLEY DR STE 100
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9118
Practice Address - Country:US
Practice Address - Phone:734-995-5181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005570103TC0700X
MI6301018412103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical