Provider Demographics
NPI:1952463226
Name:JARDINE, DOUGLAS SEYMOUR JR (PHD, LMFT)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:SEYMOUR
Last Name:JARDINE
Suffix:JR
Gender:M
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:DOUGLAS
Other - Middle Name:S
Other - Last Name:JARDINE
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2649 E BEEKMAN PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7485
Mailing Address - Country:US
Mailing Address - Phone:602-538-9094
Mailing Address - Fax:
Practice Address - Street 1:2649 E BEEKMAN PL
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7485
Practice Address - Country:US
Practice Address - Phone:602-538-9094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10136106H00000X
AZ11406106H00000X
AZLMFT10136106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ817132OtherAHCCCS