MEDICARE: JORDAN BLAKENEY

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	106S00000X	Behavior Technician
2	101YM0800X	Mental Health Counselor	8745	SC

General Provider Information

NPI Number	:	1952033847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN BLAKENEY

Provider Business Mailing Address
First Line	:	1906 MEREVIEW CT UNIT 9
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-7496
Country	:	US
Telephone Number	:	704-957-4971
Fax Number	:

Provider Business Practice Location Address
First Line	:	1036 ASSEMBLY DR
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-6400
Country	:	US
Telephone Number	:	980-250-2438
Fax Number	:

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

Provider Enumeration Date	:	06/29/2022
Last Update Date	:	11/14/2023

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Directions to “ JORDAN BLAKENEY ” Practice Location

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