Provider Demographics
NPI:1689155350
Name:LYLE, JORDAN KATHERINE (LGPC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:KATHERINE
Last Name:LYLE
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 KINGS HEATHER DR
Mailing Address - Street 2:
Mailing Address - City:MITCHELLVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-2037
Mailing Address - Country:US
Mailing Address - Phone:240-475-6633
Mailing Address - Fax:
Practice Address - Street 1:7404 EXECUTIVE PL STE 102
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-6230
Practice Address - Country:US
Practice Address - Phone:240-803-3297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP8914101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health