1952389116 NPI number — DR. JUDITH VICTORIA JORDAN PH.D.

Table of content: DR. JUDITH VICTORIA JORDAN PH.D. (NPI 1952389116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952389116 NPI number — DR. JUDITH VICTORIA JORDAN PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JORDAN
Provider First Name:
JUDITH
Provider Middle Name:
VICTORIA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952389116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29 BARBERRY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02421-8025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-855-2140
Provider Business Mailing Address Fax Number:
781-860-9592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 WALTHAM ST
Provider Second Line Business Practice Location Address:
SUITE 17
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02421-5415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-855-2149
Provider Business Practice Location Address Fax Number:
781-860-9592
Provider Enumeration Date:
01/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  1019 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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