Healthcare Provider Details

I. General information

NPI: 1558089300
Provider Name (Legal Business Name): JORDAN SOUTHERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 S GOLD ST STE 4
CENTRALIA WA
98531-8930
US

IV. Provider business mailing address

1902 AHLERS AVE APT 2
CENTRALIA WA
98531-3479
US

V. Phone/Fax

Practice location:
  • Phone: 360-261-6930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: