Provider Demographics
NPI:1699148080
Name:MITCHENER, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:MITCHENER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 456
Mailing Address - Street 2:
Mailing Address - City:BURGAW
Mailing Address - State:NC
Mailing Address - Zip Code:28425-0456
Mailing Address - Country:US
Mailing Address - Phone:910-540-2590
Mailing Address - Fax:
Practice Address - Street 1:2207 DELANEY DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5263
Practice Address - Country:US
Practice Address - Phone:336-684-9951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-06
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-22136101YA0400X
NCA12294101YP2500X
NC12294101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)