Healthcare Provider Details

I. General information

NPI: 1427227131
Provider Name (Legal Business Name): JACQUELINE JORDAN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 SOUTHERN BLVD
BRONX NY
10459-2417
US

IV. Provider business mailing address

1065 SOUTHERN BLVD
BRONX NY
10459-2417
US

V. Phone/Fax

Practice location:
  • Phone: 718-589-2440
  • Fax: 718-589-7558
Mailing address:
  • Phone: 718-589-2440
  • Fax: 718-589-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number076511-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: