Healthcare Provider Details

I. General information

NPI: 1568375434
Provider Name (Legal Business Name): HALLY JORDAN M.ED. ALC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 COWLES ST
FAIRBANKS AK
99701-5918
US

IV. Provider business mailing address

2111 COWLES ST
FAIRBANKS AK
99701-5918
US

V. Phone/Fax

Practice location:
  • Phone: 907-458-2644
  • Fax: 907-459-3521
Mailing address:
  • Phone: 907-458-2644
  • Fax: 907-459-3521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number260391
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: