Provider Demographics
NPI:1306696224
Name:JOHANSEN, JORDAN (LMSW)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 S SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-6732
Mailing Address - Country:US
Mailing Address - Phone:480-490-8505
Mailing Address - Fax:
Practice Address - Street 1:8079 N 85TH WAY
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4321
Practice Address - Country:US
Practice Address - Phone:480-261-5015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-177491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical