Healthcare Provider Details

I. General information

NPI: 1245363225
Provider Name (Legal Business Name): JORDAN PREBYS LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 10/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 NORTH WARDER STREET SUITE 165
SPRINGFIELD OH
45504
US

IV. Provider business mailing address

5959 E CASSTOWN CLARK RD
CASSTOWN OH
45312-9746
US

V. Phone/Fax

Practice location:
  • Phone: 937-717-8643
  • Fax:
Mailing address:
  • Phone: 937-717-8643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2005028614
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number66365
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE. 1200737
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: