Provider Demographics
NPI:1588781793
Name:JORDAN, CILLY (LPC-S, LSOTP)
Entity type:Individual
Prefix:
First Name:CILLY
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LPC-S, LSOTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 BUNTON CREEK RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-5787
Mailing Address - Country:US
Mailing Address - Phone:512-217-6072
Mailing Address - Fax:512-268-2759
Practice Address - Street 1:135 BUNTON CREEK RD
Practice Address - Street 2:SUITE 304
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-5787
Practice Address - Country:US
Practice Address - Phone:512-217-6072
Practice Address - Fax:512-268-2759
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLSOTP 98981101Y00000X
TX19069101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1737843-01Medicaid
TX7447LCOtherBCBS TPI