=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821365644
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONNA MARIE JORDAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2011
-----------------------------------------------------
Last Update Date | 07/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 824 N 99TH AVE
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323-5324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-808-2121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126 S 220TH DR
-----------------------------------------------------
City | BUCKEYE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85326-8971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-372-1481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC-19058
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------