Provider Demographics
NPI:1902457682
Name:JORDAN, KEYANA TANIE
Entity type:Individual
Prefix:MS
First Name:KEYANA
Middle Name:TANIE
Last Name:JORDAN
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 1:4508 CROWNE LAKE CIR APT 1D
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-7921
Mailing Address - Country:US
Mailing Address - Phone:252-314-7403
Mailing Address - Fax:
Practice Address - Street 1:4508 CROWNE LAKE CIR APT 1D
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NC
Practice Address - Zip Code:27282-7921
Practice Address - Country:US
Practice Address - Phone:252-314-7403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-25905101YA0400X
NCA15383101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)