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General NPI Number Information
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NPI Number | 1134725799
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Entity Type | Individual
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Provider Name | JORDAN LEE WHEALDON LSW
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Gender | Female
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Dates
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Enumeration Date | 12/09/2020
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Last Update Date | 12/09/2020
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Provider Practice Location Address
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Address Line | 6417 W IRVING PARK RD
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City | CHICAGO
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State | IL
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Zip | 60634-2437
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Country | US
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Telephone | 773-777-7112
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Fax |
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Provider Business Mailing Address
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Address Line | 1101 W COLUMBIA AVE APT 202
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City | CHICAGO
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State | IL
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Zip | 60626-4581
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Country | US
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Telephone | 937-728-0225
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 150104805
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License Number State | IL
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