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General NPI Number Information
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NPI Number | 1699085993
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Entity Type | Organization
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Legal Business Name | TRACY JORDAN, LCSW-C
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Dates
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Enumeration Date | 10/20/2010
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Last Update Date | 10/20/2010
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Provider Practice Location Address
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Address Line | 9650 SANTIAGO RD STE 3
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City | COLUMBIA
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State | MD
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Zip | 21045-3960
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Country | US
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Telephone | 410-446-5678
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Fax |
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Provider Business Mailing Address
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Address Line | 2190 OAK FOREST DR
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City | ELLICOTT CITY
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State | MD
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Zip | 21043-1966
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Country | US
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Telephone | 410-446-5678
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL SOCIAL WORKER
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Name | MS. TRACY SUZANNE JORDAN
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Credential | LCSW-C
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Telephone | 410-446-5678
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 12109
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License Number State | MD
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