Provider Demographics
NPI:1063623130
Name:JORDAN, DARRELL SR (LCSW, DCSW)
Entity type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:
Last Name:JORDAN
Suffix:SR
Gender:M
Credentials:LCSW, DCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2433
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79604-2433
Mailing Address - Country:US
Mailing Address - Phone:229-395-0151
Mailing Address - Fax:
Practice Address - Street 1:1020 CEDAR CREST DR
Practice Address - Street 2:APT C-9
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-3714
Practice Address - Country:US
Practice Address - Phone:229-395-0151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1273-LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000663506Medicaid
GA000663506Medicaid