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General NPI Number Information
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NPI Number | 1265077812
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Entity Type | Individual
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Provider Name | JORDAN KOEGLE LISW
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Gender | Male
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Dates
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Enumeration Date | 11/07/2019
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Last Update Date | 06/17/2021
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Provider Practice Location Address
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Address Line | 3964 HAMILTON SQUARE BLVD
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City | GROVEPORT
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State | OH
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Zip | 43125-9119
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Country | US
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Telephone | 614-610-1506
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Fax | 614-834-8694
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Provider Business Mailing Address
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Address Line | 3964 HAMILTON SQUARE BLVD
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City | GROVEPORT
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State | OH
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Zip | 43125-9119
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Country | US
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Telephone | 614-610-1506
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Fax | 614-834-8694
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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 | S.1600951
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | I2102753
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License Number State | OH
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