Provider Demographics
NPI:1730512500
Name:DALZELL, JORDAN GERARD
Entity type:Individual
Prefix:MS
First Name:JORDAN
Middle Name:GERARD
Last Name:DALZELL
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 1:1 FISCHER RD
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-1339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 FISCHER RD
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1339
Practice Address - Country:US
Practice Address - Phone:609-226-9084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical