Provider Demographics
NPI:1427619857
Name:BLADES, JORDAN T (LAC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:T
Last Name:BLADES
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 SW 21ST ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66604-3412
Mailing Address - Country:US
Mailing Address - Phone:785-266-0202
Mailing Address - Fax:
Practice Address - Street 1:4015 SW 21ST ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66604-3412
Practice Address - Country:US
Practice Address - Phone:785-266-0202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1669101YA0400X
KS1642101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)