Provider Demographics
NPI:1285873745
Name:JORDAN, KIMBERLY MICHELLE (LADAC, LMFT, CPRP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LADAC, LMFT, CPRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6727
Mailing Address - Country:US
Mailing Address - Phone:575-649-8518
Mailing Address - Fax:
Practice Address - Street 1:1215 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6727
Practice Address - Country:US
Practice Address - Phone:575-649-8518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-06
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171007172V00000X, 171M00000X
CARI-J0811051803101YA0400X
NM014701101YA0400X
NM0176661106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)