Basic Information
| Provider Information | |||||||||
| NPI: | 1396110763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JENKINS | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6051 DAVIS BLVD | ||||||||
| Address2: | #821277 | ||||||||
| City: | NORTH RICHLAND HILLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761806385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178512042 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6051 DAVIS BLVD | ||||||||
| Address2: | #821277 | ||||||||
| City: | NORTH RICHLAND HILLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761806385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178512042 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2015 | ||||||||
| LastUpdateDate: | 12/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 71765 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.