Healthcare Provider Details

I. General information

NPI: 1659285096
Provider Name (Legal Business Name): KELLY JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E RAILROAD AVE STE 210
WASILLA AK
99654-8137
US

IV. Provider business mailing address

PO BOX 870606
WASILLA AK
99687-0606
US

V. Phone/Fax

Practice location:
  • Phone: 907-313-7965
  • Fax: 907-531-3886
Mailing address:
  • Phone: 907-313-7965
  • Fax: 907-531-3886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: