Healthcare Provider Details

I. General information

NPI: 1588620827
Provider Name (Legal Business Name): JILL ELAINE JORDAN L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 HIGHLAND AVE
COLONIAL HEIGHTS VA
23834-3139
US

IV. Provider business mailing address

PO BOX 1913
PETERSBURG VA
23805-0913
US

V. Phone/Fax

Practice location:
  • Phone: 804-520-5859
  • Fax: 804-733-2070
Mailing address:
  • Phone: 804-520-5859
  • Fax: 804-733-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904001306
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: