Basic Information
| Provider Information | |||||||||
| NPI: | 1275736159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 814 W CENTER ST | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721508402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704843938 | ||||||||
| FaxNumber: | 8709423960 | ||||||||
| Practice Location | |||||||||
| Address1: | 1719 MERRILL DR | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722124009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016632199 | ||||||||
| FaxNumber: | 5016632234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2007 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | P0507050 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 205087719 | 05 | AR | MEDICAID |