Healthcare Provider Details

I. General information

NPI: 1972373488
Provider Name (Legal Business Name): JORDAN SCOTT BOGENRIEF LPC SUPERVISEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2024
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 4TH ST
BROOKINGS SD
57006-2003
US

IV. Provider business mailing address

418 4TH ST
BROOKINGS SD
57006-2003
US

V. Phone/Fax

Practice location:
  • Phone: 605-697-3002
  • Fax:
Mailing address:
  • Phone: 605-697-3002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number20859
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: