MEDICARE: MR. JORDAN L GRIFFIE LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	A1804044	AR
2	101YM0800X	Mental Health Counselor	P2008056	AR
3	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1104303338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JORDAN L GRIFFIE LPC

Provider Business Mailing Address
First Line	:	6901 DALLAS ST STE A
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-5037
Country	:	US
Telephone Number	:	479-222-6210
Fax Number	:	479-222-6895

Provider Business Practice Location Address
First Line	:	6901 DALLAS ST STE A
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-5037
Country	:	US
Telephone Number	:	479-222-6210
Fax Number	:	479-222-6895

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2018
Last Update Date	:	07/29/2022

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