Healthcare Provider Details

I. General information

NPI: 1790240513
Provider Name (Legal Business Name): JORDAN E JONES LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2019
Last Update Date: 05/28/2022
Certification Date: 05/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 N MAIN ST
DECATUR IL
62523-1206
US

IV. Provider business mailing address

151 N MAIN ST
DECATUR IL
62523-1206
US

V. Phone/Fax

Practice location:
  • Phone: 217-362-6262
  • Fax: 217-366-6290
Mailing address:
  • Phone: 217-362-6262
  • Fax: 217-366-6290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number150-103309
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149-022061
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: