Provider Demographics
NPI:1487322137
Name:BANKS, JORDAN ROBERT (CT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ROBERT
Last Name:BANKS
Suffix:
Gender:M
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5209 DETROIT AVENUE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102
Mailing Address - Country:US
Mailing Address - Phone:216-651-2037
Mailing Address - Fax:
Practice Address - Street 1:5209 DETROIT AVENUE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102
Practice Address - Country:US
Practice Address - Phone:216-651-2037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X, 172V00000X
OHC.2305565101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0459264Medicaid