=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740810712
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JORDAN COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2020
-----------------------------------------------------
Last Update Date | 01/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 HIGHLAND COLONY PKWY STE 5203
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39157-2079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-566-5899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 CAMDEN LN
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39110-4016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-566-5899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CERTIFIED SOCIAL WORKER
-----------------------------------------------------
Name | MR. DAVID R JORDAN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 601-566-5899
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------