Provider Demographics
NPI:1699085993
Name:TRACY JORDAN, LCSW-C
Entity type:Organization
Organization Name:TRACY JORDAN, LCSW-C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:410-446-5678
Mailing Address - Street 1:2190 OAK FOREST DR
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-1966
Mailing Address - Country:US
Mailing Address - Phone:410-446-5678
Mailing Address - Fax:
Practice Address - Street 1:9650 SANTIAGO RD STE 3
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3960
Practice Address - Country:US
Practice Address - Phone:410-446-5678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD121091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD122305OtherJOHNS HOPKINS HEALTHCARE