Basic Information
| Provider Information | |||||||||
| NPI: | 1992224737 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 BLAZING CT | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454313521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542619380 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1349 E STROOP RD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454294925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372938300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2017 | ||||||||
| LastUpdateDate: | 09/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1701057 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.