Basic Information
| Provider Information | |||||||||
| NPI: | 1689804742 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | LEIGH | ||||||||
| MiddleName: | DIXIE | ||||||||
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| Credential: | LSCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MAINE ST STE A | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660441396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858439192 | ||||||||
| FaxNumber: | 7858436711 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MAINE ST STE A | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660441396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858439192 | ||||||||
| FaxNumber: | 7858436711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2009 | ||||||||
| LastUpdateDate: | 07/26/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 7450 | KS | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 4565 | KS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1841281805 | 05 | KS | MEDICAID |