=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790327716
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN PHILIP LEFLER LSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2019
-----------------------------------------------------
Last Update Date | 10/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 850 LEONARD ST
-----------------------------------------------------
City | CLEARFIELD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16830-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-205-4004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5139 WAYNE RD
-----------------------------------------------------
City | DU BOIS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15801-5775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-590-8414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | SW136563
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------