MEDICARE: REGINALD JORDAN LCSW

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

General Provider Information

NPI Number	:	1922567346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REGINALD JORDAN LCSW

Provider Business Mailing Address
First Line	:	2360 RANGER DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76120-5630
Country	:	US
Telephone Number	:	469-337-0321
Fax Number	:

Provider Business Practice Location Address
First Line	:	2360 RANGER DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76120-5630
Country	:	US
Telephone Number	:	469-337-0321
Fax Number	:

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

Provider Enumeration Date	:	03/15/2019
Last Update Date	:	03/15/2019

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