Provider Demographics
NPI:1710484985
Name:MORTIMER, JORDANA ELYSE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JORDANA
Middle Name:ELYSE
Last Name:MORTIMER
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 1:6909 CHURCH PARK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-6856
Mailing Address - Country:US
Mailing Address - Phone:817-845-1562
Mailing Address - Fax:
Practice Address - Street 1:1208 W MAGNOLIA AVE STE 234
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-8801
Practice Address - Country:US
Practice Address - Phone:817-989-6312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70174103TS0200X
TX36926103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool