Provider Demographics
NPI:1619177409
Name:JORDAN, SHIRLEY JEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:JEAN
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 1:504 N MILLER ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-1114
Mailing Address - Country:US
Mailing Address - Phone:940-627-1690
Mailing Address - Fax:
Practice Address - Street 1:506 N MILLER ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-1114
Practice Address - Country:US
Practice Address - Phone:940-627-1690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-3168103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1132268-0Medicaid
TX1132268-0Medicaid
TX00030Medicare PIN