Provider Demographics
NPI:1356567200
Name:JORDAN, RICHARD (PSYD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 MARLBOROUGH DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-2020
Mailing Address - Country:US
Mailing Address - Phone:619-303-5062
Mailing Address - Fax:619-303-5062
Practice Address - Street 1:5100 MARLBOROUGH DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-2020
Practice Address - Country:US
Practice Address - Phone:619-303-5062
Practice Address - Fax:619-303-5062
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16697103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist