Healthcare Provider Details

I. General information

NPI: 1194591701
Provider Name (Legal Business Name): JORDAN KOTLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

766 N 44TH ST
PHILADELPHIA PA
19104-1362
US

IV. Provider business mailing address

2201 PENNSYLVANIA AVE APT 212
PHILADELPHIA PA
19130-3521
US

V. Phone/Fax

Practice location:
  • Phone: 215-823-8203
  • Fax:
Mailing address:
  • Phone: 301-793-2316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberSW138282
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: