Healthcare Provider Details

I. General information

NPI: 1649937368
Provider Name (Legal Business Name): JORDON WAYNE WEAVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 CREEKVIEW CT
MARION NC
28752-6519
US

IV. Provider business mailing address

686 LYTLE MOUNTAIN RD
MARION NC
28752-8482
US

V. Phone/Fax

Practice location:
  • Phone: 843-287-2650
  • Fax:
Mailing address:
  • Phone: 843-287-2650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA22294
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: