Healthcare Provider Details

I. General information

NPI: 1326485624
Provider Name (Legal Business Name): JORDAN TIVERS L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2013
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 CHURCH ST STE 321
EVANSTON IL
60201
US

IV. Provider business mailing address

636 CHURCH ST STE 321
EVANSTON IL
60201-4579
US

V. Phone/Fax

Practice location:
  • Phone: 847-791-6026
  • Fax:
Mailing address:
  • Phone: 847-791-6026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.017842
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: