MEDICARE: KELLIE MARIE JORDAN

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	101YP2500X	Professional Counselor	LPC015422	GA

General Provider Information

NPI Number	:	1306434493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE MARIE JORDAN

Provider Business Mailing Address
First Line	:	3200 HIGHLANDS PKWY SE STE 400
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30082-5192
Country	:	US
Telephone Number	:	888-588-8995
Fax Number	:

Provider Business Practice Location Address
First Line	:	3200 HIGHLANDS PKWY SE STE 400
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30082-5192
Country	:	US
Telephone Number	:	888-588-8995
Fax Number	:

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

Provider Enumeration Date	:	01/05/2021
Last Update Date	:	06/08/2026

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