Healthcare Provider Details

I. General information

NPI: 1053229252
Provider Name (Legal Business Name): MS. BLANCHE JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2026
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 AVALON CIR
BRANDON MS
39047-7848
US

IV. Provider business mailing address

224 AVALON CIR
BRANDON MS
39047-7848
US

V. Phone/Fax

Practice location:
  • Phone: 601-942-5382
  • Fax:
Mailing address:
  • Phone: 601-942-5382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPLC-1066
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: