Provider Demographics
NPI:1104937952
Name:JORDAN, ROBERT HERBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:HERBERT
Last Name:JORDAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2047 CAPTAIN SHREVE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-3819
Mailing Address - Country:US
Mailing Address - Phone:318-861-0167
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:OVERTON BROOKS VA MEDICAL CENTER--116B
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-424-6051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA546103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist