Healthcare Provider Details

I. General information

NPI: 1083326409
Provider Name (Legal Business Name): ELIZABETH JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2022
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 HIGHWAY 80 W
JACKSON MS
39209-7201
US

IV. Provider business mailing address

3225 COREY DR
JACKSON MS
39212-4112
US

V. Phone/Fax

Practice location:
  • Phone: 601-321-2400
  • Fax:
Mailing address:
  • Phone: 769-972-4733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: