MEDICARE: JORDYN MARIE WITTY LCSW

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	LMSW-42257	ID
2	101YM0800X	Mental Health Counselor	23-QMHP-R-2188	OR
3	1041C0700X	Clinical Social Worker	LMSW-42257	ID
4	1041C0700X	Clinical Social Worker	8911019	ID

General Provider Information

NPI Number	:	1366003147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDYN MARIE WITTY LCSW

Provider Business Mailing Address
First Line	:	3425 13TH ST
Second Line	:
City	:	BAKER CITY
State	:	OR
Zip	:	97814-1340
Country	:	US
Telephone Number	:	542-523-7400
Fax Number	:	541-523-4927

Provider Business Practice Location Address
First Line	:	3071 E FRANKLIN RD STE 201
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-2376
Country	:	US
Telephone Number	:	208-807-2877
Fax Number	:	208-807-2888

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

Provider Enumeration Date	:	06/24/2019
Last Update Date	:	04/29/2026

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