Healthcare Provider Details

I. General information

NPI: 1447860572
Provider Name (Legal Business Name): JORDAN MCEUEN TCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 S ROY WILKINS AVE STE 100
LOUISVILLE KY
40203-2072
US

IV. Provider business mailing address

720 W BROADWAY STE 202
LOUISVILLE KY
40202-3245
US

V. Phone/Fax

Practice location:
  • Phone: 502-583-4092
  • Fax: 502-371-6110
Mailing address:
  • Phone: 502-561-0943
  • Fax: 502-561-0944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number263002
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: