Provider Demographics
NPI:1326683145
Name:JORDAN, ROSLYN M (LPC)
Entity type:Individual
Prefix:
First Name:ROSLYN
Middle Name:M
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 SANTA MONICA BLVD APT 207
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-3610
Mailing Address - Country:US
Mailing Address - Phone:312-857-5653
Mailing Address - Fax:
Practice Address - Street 1:525 SANTA MONICA BLVD APT 207
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-3610
Practice Address - Country:US
Practice Address - Phone:312-857-5653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-15
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.015694101YP2500X
IL178.014415101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional