Healthcare Provider Details

I. General information

NPI: 1710380035
Provider Name (Legal Business Name): KELLI JORDAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 10/22/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 DELUCA DR
SCIENCE HILL KY
42553-9053
US

IV. Provider business mailing address

162 DELUCA DR
SCIENCE HILL KY
42553-9053
US

V. Phone/Fax

Practice location:
  • Phone: 859-428-7374
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number252744
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: