Provider Demographics
NPI:1194350496
Name:PRUSSACK, JORDAN SIERRA (LCSW)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:SIERRA
Last Name:PRUSSACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6593 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:NINE MILE FLS
Mailing Address - State:WA
Mailing Address - Zip Code:99026-9544
Mailing Address - Country:US
Mailing Address - Phone:503-449-1807
Mailing Address - Fax:
Practice Address - Street 1:1417 9TH ST S STE 300
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4509
Practice Address - Country:US
Practice Address - Phone:503-449-1807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-333221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical