Healthcare Provider Details

I. General information

NPI: 1821757196
Provider Name (Legal Business Name): JORDAN MICKENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 WILLARD AVE
CHEVY CHASE MD
20815-3690
US

IV. Provider business mailing address

2929 FM 2920 RD
SPRING TX
77388-3428
US

V. Phone/Fax

Practice location:
  • Phone: 323-205-7088
  • Fax: 833-419-0181
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25097
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: