MEDICARE: AMY JORDAN LMHC

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	IMH10299	FL

General Provider Information

NPI Number	:	1801224787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY JORDAN LMHC

Provider Business Mailing Address
First Line	:	6767 N WICKHAM RD STE 400D
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32940-2025
Country	:	US
Telephone Number	:	321-698-4011
Fax Number	:

Provider Business Practice Location Address
First Line	:	6767 N WICKHAM RD STE 400D
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32940-2025
Country	:	US
Telephone Number	:	321-698-4011
Fax Number	:

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

Provider Enumeration Date	:	10/31/2013
Last Update Date	:	11/12/2020

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