Provider Demographics
NPI:1356589873
Name:MACK, JORDAN M
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:M
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 131
Mailing Address - Street 2:
Mailing Address - City:SOPER
Mailing Address - State:OK
Mailing Address - Zip Code:74759-9632
Mailing Address - Country:US
Mailing Address - Phone:580-317-5209
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 131
Practice Address - Street 2:
Practice Address - City:SOPER
Practice Address - State:OK
Practice Address - Zip Code:74759-9632
Practice Address - Country:US
Practice Address - Phone:580-317-5209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation