Provider Demographics
NPI:1306160080
Name:JORDAN, MANDY J (PHD)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:J
Last Name:JORDAN
Suffix:
Gender:F
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:PO BOX 202636
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78720-2636
Mailing Address - Country:US
Mailing Address - Phone:817-916-8200
Mailing Address - Fax:817-717-6571
Practice Address - Street 1:12416 BEARTRAP LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78729-7938
Practice Address - Country:US
Practice Address - Phone:817-916-8200
Practice Address - Fax:817-717-6571
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34438103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX212411701Medicaid
TX212411701Medicaid
TX88008AOtherBCBS
TX212411701Medicaid