MEDICARE: THOMAS H JORDAN JR. LCADC - NJ

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	37LC00180300	NJ

General Provider Information

NPI Number	:	1710233051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS H JORDAN JR. LCADC - NJ

Provider Business Mailing Address
First Line	:	302 HAWTHORNE AVE
Second Line	:
City	:	POINT PLEASANT BEACH
State	:	NJ
Zip	:	08742-2539
Country	:	US
Telephone Number	:	732-899-1511
Fax Number	:	732-892-0984

Provider Business Practice Location Address
First Line	:	302 HAWTHORNE AVE
Second Line	:
City	:	POINT PLEASANT BEACH
State	:	NJ
Zip	:	08742-2539
Country	:	US
Telephone Number	:	732-899-1511
Fax Number	:	732-892-0984

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

Provider Enumeration Date	:	07/24/2012
Last Update Date	:	07/24/2012

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