Healthcare Provider Details

I. General information

NPI: 1134680846
Provider Name (Legal Business Name): JORDAN SHARP LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 03/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 NE MARKET DR
FAIRVIEW OR
97024-7000
US

IV. Provider business mailing address

3710 SW US VETERANS HOSPITAL RD
PORTLAND OR
97239-2964
US

V. Phone/Fax

Practice location:
  • Phone: 503-273-5142
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL7433
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: