=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841823515
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN ANDERSON ROYALS LPC, NCC, CMHT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2020
-----------------------------------------------------
Last Update Date | 09/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6880 COBBLESTONE BLVD STE 1
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38672-9313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 622-253-8324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6880 COBBLESTONE BLVD STE 1
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38672-9313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 622-253-8324
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 1516
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2642
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------