Healthcare Provider Details

I. General information

NPI: 1831858869
Provider Name (Legal Business Name): JORDAN MARTIN HENDRIX LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JORDAN RAY MARTIN LSW

II. Dates (important events)

Enumeration Date: 12/17/2021
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4039 GATEWAY BLVD
GROVETOWN GA
30813-3389
US

IV. Provider business mailing address

627 STEVENS XING
MARTINEZ GA
30907-9566
US

V. Phone/Fax

Practice location:
  • Phone: 706-498-9570
  • Fax:
Mailing address:
  • Phone: 334-723-6368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW12393
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number1804701
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMSW008172
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: