Provider Demographics
NPI:1992817563
Name:JORDAN, MISTY MICHELE
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:MICHELE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 SEQUOIA PARK DR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-5819
Mailing Address - Country:US
Mailing Address - Phone:405-354-5645
Mailing Address - Fax:
Practice Address - Street 1:200 N CHOCTAW AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-2624
Practice Address - Country:US
Practice Address - Phone:405-262-3209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health