Provider Demographics
NPI:1619000346
Name:JORDAN, LISA C (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:C
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 1:583 FREDERICK RD
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-4697
Mailing Address - Country:US
Mailing Address - Phone:410-747-7991
Mailing Address - Fax:410-747-5188
Practice Address - Street 1:583 FREDERICK RD
Practice Address - Street 2:SUITE 5A
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-4697
Practice Address - Country:US
Practice Address - Phone:410-747-7991
Practice Address - Fax:410-747-5188
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03876103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD618358-01OtherBLUE CROSS BLUE SHIELD
MD100093259001OtherAPS
MD618358-01OtherBLUE CROSS BLUE SHIELD