Healthcare Provider Details

I. General information

NPI: 1154748747
Provider Name (Legal Business Name): TIFFANY JORDAN LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2014
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6615 N BIG HOLLOW RD
PEORIA IL
61615
US

IV. Provider business mailing address

6615 N BIG HOLLOW RD
PEORIA IL
61615-2450
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-6622
  • Fax: 309-692-6952
Mailing address:
  • Phone: 309-692-6622
  • Fax: 309-692-6952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180009045
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180.009045
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: