Provider Demographics
NPI:1831252386
Name:JORDAN, STACY M (MA CCC-A)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MA CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4295
Mailing Address - Country:US
Mailing Address - Phone:802-863-7326
Mailing Address - Fax:
Practice Address - Street 1:108 CHERRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4295
Practice Address - Country:US
Practice Address - Phone:802-863-7326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008071Medicaid