Healthcare Provider Details

I. General information

NPI: 1659868396
Provider Name (Legal Business Name): KIMBERLY JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 GRANT ST
PORTSMOUTH OH
45662-3663
US

IV. Provider business mailing address

729 6TH ST
PORTSMOUTH OH
45662-4030
US

V. Phone/Fax

Practice location:
  • Phone: 740-901-0416
  • Fax: 740-529-1205
Mailing address:
  • Phone: 740-876-8290
  • Fax: 740-529-1205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.177568
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: