Provider Demographics
NPI:1285420778
Name:KELLEY, JORDAN (LMSW)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:
Credentials:LMSW
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:LAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:40432 WAHA GLEN RD
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5287
Mailing Address - Country:US
Mailing Address - Phone:253-740-0025
Mailing Address - Fax:
Practice Address - Street 1:514 THAIN RD UNIT B
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5533
Practice Address - Country:US
Practice Address - Phone:208-746-3398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-19
Last Update Date:2025-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3861573104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker