Provider Demographics
NPI:1518783984
Name:JORDAN, EILEEN
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 UPPER BAY RD
Mailing Address - Street 2:
Mailing Address - City:SANBORNTON
Mailing Address - State:NH
Mailing Address - Zip Code:03269-2723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 FALCON WAY
Practice Address - Street 2:
Practice Address - City:BOW
Practice Address - State:NH
Practice Address - Zip Code:03304-4228
Practice Address - Country:US
Practice Address - Phone:603-228-2210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH98605103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool