Provider Demographics
NPI:1487430542
Name:FRASER, JORDYNN MICHELLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JORDYNN
Middle Name:MICHELLE
Last Name:FRASER
Suffix:
Gender:F
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 RANDOLPH RD STE 1010
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1117
Practice Address - Country:US
Practice Address - Phone:704-384-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR202246103T00000X
NC6700103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist