Provider Demographics
NPI:1194352500
Name:HOLBROOK, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:HOLBROOK
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 1:15041 BAXTER VILLAGE DR APT D
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-7873
Mailing Address - Country:US
Mailing Address - Phone:423-298-8653
Mailing Address - Fax:
Practice Address - Street 1:222 S MERAMEC AVE STE 303
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-3514
Practice Address - Country:US
Practice Address - Phone:423-298-8653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018045606101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional