Provider Demographics
NPI:1720094683
Name:PAUKER, JORDAN L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:L
Last Name:PAUKER
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 1:253 SHINNECOCK DR
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-9524
Mailing Address - Country:US
Mailing Address - Phone:732-431-2171
Mailing Address - Fax:732-409-3634
Practice Address - Street 1:75 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2114
Practice Address - Country:US
Practice Address - Phone:732-431-2171
Practice Address - Fax:732-409-3634
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1695103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ053844Medicare ID - Type Unspecified