Healthcare Provider Details

I. General information

NPI: 1891589610
Provider Name (Legal Business Name): ANDREW J JORDAN SSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ANDREW J FADDIS

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12760 S PARK AVE UNIT 520
RIVERTON UT
84065-3422
US

IV. Provider business mailing address

12760 S PARK AVE UNIT 520
RIVERTON UT
84065-3422
US

V. Phone/Fax

Practice location:
  • Phone: 801-407-0047
  • Fax: 888-400-9232
Mailing address:
  • Phone: 801-407-0047
  • Fax: 888-400-9232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12680519-3503
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: