Provider Demographics
NPI:1639102551
Name:JORDAN, AUGUSTUS E (PHD)
Entity type:Individual
Prefix:DR
First Name:AUGUSTUS
Middle Name:E
Last Name:JORDAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 S STREET EXT
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-8982
Mailing Address - Country:US
Mailing Address - Phone:802-388-8360
Mailing Address - Fax:802-443-2772
Practice Address - Street 1:152 MAPLE ST
Practice Address - Street 2:SUITE 202
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1370
Practice Address - Country:US
Practice Address - Phone:802-989-1555
Practice Address - Fax:802-443-2772
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048-0000843103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010775Medicaid
VT68375OtherBLUE CROSS BLUE SHIELD VT