Healthcare Provider Details

I. General information

NPI: 1295378289
Provider Name (Legal Business Name): JORDAN BAKER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 02/14/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 MUSEUM RD
CONWAY AR
72032-4785
US

IV. Provider business mailing address

PO BOX 497
AUGUSTA AR
72006-0497
US

V. Phone/Fax

Practice location:
  • Phone: 501-932-9010
  • Fax: 501-932-0020
Mailing address:
  • Phone: 870-347-2534
  • Fax: 870-301-2092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9560-M
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9560-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: