Healthcare Provider Details

I. General information

NPI: 1104262427
Provider Name (Legal Business Name): BETH A JORDAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14675 DOWNEY RD
CAPAC MI
48014
US

IV. Provider business mailing address

3111 ELECTRIC AVE
PORT HURON MI
48060-8127
US

V. Phone/Fax

Practice location:
  • Phone: 810-395-4343
  • Fax:
Mailing address:
  • Phone: 810-985-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401017317
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: