MEDICARE: JORDAN LIST BA

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	22212	OK
2	171M00000X	Case Manager/Care Coordinator
3	104100000X	Social Worker	20487-P	OK

General Provider Information

NPI Number	:	1528685419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN LIST BA

Provider Business Mailing Address
First Line	:	4144 E 38TH ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74135-2502
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2227 E SKELLY DR
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74105-5913
Country	:	US
Telephone Number	:	918-728-2228
Fax Number	:

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

Provider Enumeration Date	:	06/26/2020
Last Update Date	:	03/11/2026

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Directions to “ JORDAN LIST BA” Practice Location

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