MEDICARE: JORDAN BURNS LISW-S

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	1041C0700X	Clinical Social Worker	I.1600719-SUPV	OH

General Provider Information

NPI Number	:	1336552231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN BURNS LISW-S

Provider Business Mailing Address
First Line	:	1865 N RIDGE RD E STE D
Second Line	:
City	:	LORAIN
State	:	OH
Zip	:	44055-3359
Country	:	US
Telephone Number	:	440-723-5498
Fax Number	:	440-277-0459

Provider Business Practice Location Address
First Line	:	1865 N RIDGE RD E STE D
Second Line	:
City	:	LORAIN
State	:	OH
Zip	:	44055-3359
Country	:	US
Telephone Number	:	440-723-5498
Fax Number	:

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

Provider Enumeration Date	:	06/09/2014
Last Update Date	:	08/06/2019

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