MEDICARE: JORDAN BOYER WALTERS

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	149022560	IL

General Provider Information

NPI Number	:	1467046052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN BOYER WALTERS

Provider Business Mailing Address
First Line	:	3328 DRYSDALE CT
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-3217
Country	:	US
Telephone Number	:	217-273-1849
Fax Number	:

Provider Business Practice Location Address
First Line	:	503 E VANDALIA ST
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-1893
Country	:	US
Telephone Number	:	618-432-2331
Fax Number	:

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

Provider Enumeration Date	:	02/24/2021
Last Update Date	:	03/10/2026

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