Healthcare Provider Details

I. General information

NPI: 1295938132
Provider Name (Legal Business Name): RACHEL MARIE JORDAN MSW, QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. RACHEL MARIE YORK

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 E VINE ST
VIENNA IL
62995-1612
US

IV. Provider business mailing address

2400 W BLUE BLAZE TRL LOT F9
HERRIN IL
62948-6419
US

V. Phone/Fax

Practice location:
  • Phone: 615-658-2611
  • Fax: 618-658-2501
Mailing address:
  • Phone: 618-925-4122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: