Provider Demographics
NPI:1740570779
Name:DAVIS, JORDAN RAY (LPCI)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:RAY
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LPCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 LAKESIDE BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-4302
Mailing Address - Country:US
Mailing Address - Phone:972-437-4698
Mailing Address - Fax:972-690-9309
Practice Address - Street 1:2150 LAKESIDE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-4302
Practice Address - Country:US
Practice Address - Phone:972-437-4698
Practice Address - Fax:972-690-9309
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66808101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor