MEDICARE: STEPHANIE ELIZABET JORDAN LADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	305187	MN

General Provider Information

NPI Number	:	1669958419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE ELIZABET JORDAN LADC

Provider Business Mailing Address
First Line	:	360 PIERCE AVE STE 206
Second Line	:
City	:	NORTH MANKATO
State	:	MN
Zip	:	56003-2250
Country	:	US
Telephone Number	:	507-229-0350
Fax Number	:	507-216-0371

Provider Business Practice Location Address
First Line	:	1826 COMMERCE DR
Second Line	:
City	:	NORTH MANKATO
State	:	MN
Zip	:	56003-1800
Country	:	US
Telephone Number	:	507-229-0350
Fax Number	:	507-216-0371

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

Provider Enumeration Date	:	07/16/2018
Last Update Date	:	09/29/2023

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