Provider Demographics
NPI:1285393108
Name:GARDNER, JORDYNN MARIE (CSUDC)
Entity type:Individual
Prefix:
First Name:JORDYNN
Middle Name:MARIE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:CSUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 E 200 N STE 101
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-2834
Mailing Address - Country:US
Mailing Address - Phone:435-610-1696
Mailing Address - Fax:
Practice Address - Street 1:192 E 200 N STE 101
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-2834
Practice Address - Country:US
Practice Address - Phone:435-610-1696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12403870-6005101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1780216507Medicaid