Provider Demographics
NPI:1255635967
Name:WIEDERSTEIN, JORDAN LEWIS (LPC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEWIS
Last Name:WIEDERSTEIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1506 BEXAR CROSSING ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1587
Mailing Address - Country:US
Mailing Address - Phone:210-208-5633
Mailing Address - Fax:210-832-5005
Practice Address - Street 1:1506 BEXAR CROSSING ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1587
Practice Address - Country:US
Practice Address - Phone:210-208-5633
Practice Address - Fax:210-832-5005
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64300101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor