Provider Demographics
NPI:1396310900
Name:MOSELY, JORDAN DAVID (PSYD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:DAVID
Last Name:MOSELY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 PIEDMONT ROW DR S STE 120
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28287-2801
Mailing Address - Country:US
Mailing Address - Phone:704-552-0116
Mailing Address - Fax:
Practice Address - Street 1:6060 PIEDMONT ROW DR S STE 120
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28287-2801
Practice Address - Country:US
Practice Address - Phone:704-552-0116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC6428103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program