MEDICARE: DR. JORDAN ELLIOTT LPC, LCDC

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	222Q00000X	Developmental Therapist
2	101YM0800X	Mental Health Counselor	80261	TX

General Provider Information

NPI Number	:	1609323310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORDAN ELLIOTT LPC, LCDC

Provider Business Mailing Address
First Line	:	5837 DE ZAVALA RD.
Second Line	:	P. O. BOX 690102
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249
Country	:	US
Telephone Number	:	361-861-5155
Fax Number	:

Provider Business Practice Location Address
First Line	:	5900 BALCONES DR STE 7402
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78731-4257
Country	:	US
Telephone Number	:	208-874-7036
Fax Number	:

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

Provider Enumeration Date	:	09/10/2016
Last Update Date	:	12/05/2022

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