Provider Demographics
NPI:1104533421
Name:JERDAN, JENNY
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:JERDAN
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 1:428 SPRITE RD APT 2
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-1932
Mailing Address - Country:US
Mailing Address - Phone:502-693-0597
Mailing Address - Fax:
Practice Address - Street 1:4912 US HIGHWAY 42 STE 104
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-6357
Practice Address - Country:US
Practice Address - Phone:502-429-8437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252405104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty