MEDICARE: MR. JORDAN CAULK

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	MH20317	FL

General Provider Information

NPI Number	:	1265161715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JORDAN CAULK

Provider Business Mailing Address
First Line	:	885 MALCOLM CHANDLER LN APT 406
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-8748
Country	:	US
Telephone Number	:	636-448-4777
Fax Number	:

Provider Business Practice Location Address
First Line	:	885 MALCOLM CHANDLER LN APT 406
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-8748
Country	:	US
Telephone Number	:	636-448-4777
Fax Number	:

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

Provider Enumeration Date	:	06/09/2022
Last Update Date	:	06/09/2022

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