MEDICARE: MENYUAN JORDAN LCSW

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	1041C0700X	Clinical Social Worker	CSW007869	GA

General Provider Information

NPI Number	:	1639839863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MENYUAN JORDAN LCSW

Provider Business Mailing Address
First Line	:	107 ENTERPRISE PATH STE 300
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-2690
Country	:	US
Telephone Number	:	678-588-7982
Fax Number	:

Provider Business Practice Location Address
First Line	:	107 ENTERPRISE PATH STE 300
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-2690
Country	:	US
Telephone Number	:	678-588-7982
Fax Number	:

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

Provider Enumeration Date	:	12/29/2021
Last Update Date	:	11/04/2024

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