Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 490 | OK |
NPI | 1114263001 |
---|---|
Provider Name | Ms. Jackie D Jordan |
First Address | Oklahoma City, OK 73118-2872 |
Second Address | Oklahoma City, OK 73118-2872 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/12/2012 |
Last Update Date | 20/12/2012 |