MEDICARE: MRS. MILLICENT CLEMONS JORDAN 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	101YM0800X	Mental Health Counselor	2623	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235194218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MILLICENT CLEMONS JORDAN LPC

Provider Business Mailing Address
First Line	:	1 CARRIAGE LN
Second Line	:	BLDG. J
City	:	CHARLESTON
State	:	SC
Zip	:	29407-6060
Country	:	US
Telephone Number	:	843-573-5050
Fax Number	:	843-573-5030

Provider Business Practice Location Address
First Line	:	1 CARRIAGE LN
Second Line	:	BLDG J
City	:	CHARLESTON
State	:	SC
Zip	:	29407-6060
Country	:	US
Telephone Number	:	843-573-5050
Fax Number	:	843-573-5030

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

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	07/31/2008

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