Healthcare Provider Details

I. General information

NPI: 1457423535
Provider Name (Legal Business Name): MILLICENT C. JORDAN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CARRIAGE LN STE J
CHARLESTON SC
29407-6060
US

IV. Provider business mailing address

1 CARRIAGE LN STE J
CHARLESTON SC
29407-6060
US

V. Phone/Fax

Practice location:
  • Phone: 843-573-5050
  • Fax: 843-573-5030
Mailing address:
  • Phone: 843-573-5050
  • Fax: 843-573-5030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number328
License Number StateSC

VIII. Authorized Official

Name: MRS. MILLICENT JORDAN
Title or Position: DIRECTOR
Credential: LPC
Phone: 843-573-5050