Basic Information
| Provider Information | |||||||||
| NPI: | 1821365644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 126 S 220TH DR | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853268971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803721481 | ||||||||
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| Practice Location | |||||||||
| Address1: | 824 N 99TH AVE | ||||||||
| Address2: | |||||||||
| City: | AVONDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853235324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808082121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2011 | ||||||||
| LastUpdateDate: | 07/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC-19058 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.