Healthcare Provider Details

I. General information

NPI: 1306434493
Provider Name (Legal Business Name): KELLIE MARIE JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 HIGHLANDS PKWY SE STE 400
SMYRNA GA
30082-5192
US

IV. Provider business mailing address

3200 HIGHLANDS PKWY SE STE 400
SMYRNA GA
30082-5192
US

V. Phone/Fax

Practice location:
  • Phone: 888-588-8995
  • Fax:
Mailing address:
  • Phone: 888-588-8995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC015422
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: