Provider Demographics
NPI:1912483082
Name:WATSON, JORDAN (LPC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1534 SYCAMORE GLEN CT
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-1150
Mailing Address - Country:US
Mailing Address - Phone:770-778-7700
Mailing Address - Fax:
Practice Address - Street 1:1034 S BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63117-1223
Practice Address - Country:US
Practice Address - Phone:314-328-0496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017022183101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional