Healthcare Provider Details

I. General information

NPI: 1205502515
Provider Name (Legal Business Name): JORDAN LUISA RICKETTS MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 COMMERCIAL CENTER DR
LADSON SC
29456-4146
US

IV. Provider business mailing address

816 HYDRA LN
SUMMERVILLE SC
29486-2495
US

V. Phone/Fax

Practice location:
  • Phone: 843-314-5434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number8224
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: