Provider Demographics
NPI:1801887799
Name:JORDAN, RANDALL G (PSYD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:G
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 1:1841 HONEYSUCKLE RD
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-4269
Mailing Address - Country:US
Mailing Address - Phone:334-794-2113
Mailing Address - Fax:334-702-1220
Practice Address - Street 1:1841 HONEYSUCKLE RD
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-4269
Practice Address - Country:US
Practice Address - Phone:334-794-2113
Practice Address - Fax:334-702-1220
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL634103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL104596Medicaid
AL104596Medicaid