Provider Demographics
NPI:1063140440
Name:JORDAN, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 BRICK KILN RD
Mailing Address - Street 2:
Mailing Address - City:TEATICKET
Mailing Address - State:MA
Mailing Address - Zip Code:02536-5708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:143 BRICK KILN RD
Practice Address - Street 2:
Practice Address - City:TEATICKET
Practice Address - State:MA
Practice Address - Zip Code:02536-5708
Practice Address - Country:US
Practice Address - Phone:203-675-0961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2256631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical