MEDICARE: BRIA JORDAN-JACKSON

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	5385	TN

General Provider Information

NPI Number	:	1902534571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIA JORDAN-JACKSON

Provider Business Mailing Address
First Line	:	1 VANTAGE WAY STE E130
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37228-1591
Country	:	US
Telephone Number	:	615-988-4763
Fax Number	:

Provider Business Practice Location Address
First Line	:	1910 MADISON AVE # 2835
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38104-2620
Country	:	US
Telephone Number	:	901-609-5030
Fax Number	:

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

Provider Enumeration Date	:	08/11/2022
Last Update Date	:	07/29/2024

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