Basic Information
| Provider Information | |||||||||
| NPI: | 1881247757 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | XENIA | ||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 W FARRAGUT AVE APT 3E | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606252442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234745233 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5215 N CALIFORNIA AVE FL 7 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606257014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126663494 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2019 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 180.012336 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 180012336 | 01 | IL | ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION | OTHER |