Provider Demographics
NPI:1013229327
Name:JORDAN, HOLLY MICHELLE (MSW, LICSW, AADC)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:MICHELLE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MSW, LICSW, AADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 GREAT TEAYS BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9816
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-757-3252
Practice Address - Street 1:97 GREAT TEAYS BLVD STE 6
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-9816
Practice Address - Country:US
Practice Address - Phone:304-757-6999
Practice Address - Fax:304-757-3252
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1648101YA0400X
WVDP009439691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1013229327Medicaid
WV3810023874Medicaid
WVWV1696AMedicare PIN
WVQ45535AMedicare PIN
WV3810023874Medicaid