Healthcare Provider Details

I. General information

NPI: 1235757089
Provider Name (Legal Business Name): JORDAN MICHAEL FRIEDMAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2020
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 N 20TH AVE
PHOENIX AZ
85015-5124
US

IV. Provider business mailing address

7724 E CAMELBACK RD
SCOTTSDALE AZ
85251-2228
US

V. Phone/Fax

Practice location:
  • Phone: 602-889-9401
  • Fax:
Mailing address:
  • Phone: 847-630-7654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-18586
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: