MEDICARE: AMANDA JORDAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	366	SC
2	101YP2500X	Professional Counselor	6951	SC

General Provider Information

NPI Number	:	1083222327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA JORDAN

Provider Business Mailing Address
First Line	:	112 ESTON DR
Second Line	:
City	:	GOOSE CREEK
State	:	SC
Zip	:	29445-7131
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 ESTON DR
Second Line	:
City	:	GOOSE CREEK
State	:	SC
Zip	:	29445-7131
Country	:	US
Telephone Number	:	803-899-5283
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2020
Last Update Date	:	07/22/2020

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Directions to “ AMANDA JORDAN ” Practice Location

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