Provider Demographics
NPI:1316495302
Name:JORDAN, TODD MICHEAL (LBA, LPC)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:MICHEAL
Last Name:JORDAN
Suffix:
Gender:M
Credentials:LBA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2451 FAIR ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-7019
Mailing Address - Country:US
Mailing Address - Phone:573-429-4810
Mailing Address - Fax:
Practice Address - Street 1:2451 FAIR ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-7019
Practice Address - Country:US
Practice Address - Phone:573-429-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
2014028525101YP2500X
MO2014038770320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional