Healthcare Provider Details

I. General information

NPI: 1205455912
Provider Name (Legal Business Name): JORDAN DESAI LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JORDAN A MIRAGLIA LISW-CP

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 MAPLE ST
COLUMBIA SC
29205-1732
US

IV. Provider business mailing address

826 MAPLE ST
COLUMBIA SC
29205-1732
US

V. Phone/Fax

Practice location:
  • Phone: 301-758-5202
  • Fax:
Mailing address:
  • Phone: 301-758-5202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10048
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: