Healthcare Provider Details

I. General information

NPI: 1366003147
Provider Name (Legal Business Name): JORDYN MARIE WITTY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3071 E FRANKLIN RD STE 201
MERIDIAN ID
83642-2376
US

IV. Provider business mailing address

3425 13TH ST
BAKER CITY OR
97814-1340
US

V. Phone/Fax

Practice location:
  • Phone: 208-807-2877
  • Fax: 208-807-2888
Mailing address:
  • Phone: 542-523-7400
  • Fax: 541-523-4927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMSW-42257
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number23-QMHP-R-2188
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW-42257
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8911019
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: