Provider Demographics
NPI:1962783852
Name:MATHISEN, JORDAN DAVID (LCSW)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:DAVID
Last Name:MATHISEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203B WESTPORT DR
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-3657
Mailing Address - Country:US
Mailing Address - Phone:501-843-9233
Mailing Address - Fax:501-843-9656
Practice Address - Street 1:203B WESTPORT DR
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-3657
Practice Address - Country:US
Practice Address - Phone:501-843-9233
Practice Address - Fax:501-843-9656
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR7197-C104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6137OtherKENTUCKY BOARD OF SOCIAL WORK