Healthcare Provider Details

I. General information

NPI: 1669334751
Provider Name (Legal Business Name): JORDAN TYLOR HART CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2025
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4998 W BROAD ST STE 104
COLUMBUS OH
43228-1647
US

IV. Provider business mailing address

4079 CLABBER RD STE 105
COLUMBUS OH
43207-4207
US

V. Phone/Fax

Practice location:
  • Phone: 888-390-3779
  • Fax:
Mailing address:
  • Phone: 614-623-9862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number197246
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number197246
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: