Healthcare Provider Details

I. General information

NPI: 1366003147
Provider Name (Legal Business Name): JORDYN MARIE AYDELOTTE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 08/21/2023
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 13TH ST
BAKER CITY OR
97814-1340
US

IV. Provider business mailing address

3425 13TH ST
BAKER CITY OR
97814-1340
US

V. Phone/Fax

Practice location:
  • Phone: 542-523-7400
  • Fax: 541-523-4927
Mailing address:
  • Phone: 542-523-7400
  • Fax: 541-523-4927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW-42257
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMSW-42257
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number23-QMHP-R-2188
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: