Healthcare Provider Details

I. General information

NPI: 1083482236
Provider Name (Legal Business Name): JORDYN ABRAHAM CPSS, SUDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 14TH AVE
LONGVIEW WA
98632-2315
US

IV. Provider business mailing address

PO BOX 2394
LONGVIEW WA
98632-8455
US

V. Phone/Fax

Practice location:
  • Phone: 360-200-5419
  • Fax: 360-200-6736
Mailing address:
  • Phone: 360-200-5419
  • Fax: 844-612-6673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCO70128201
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberPE70094274
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberPR70146709
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCG61493259
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: