Provider Demographics
NPI:1043740806
Name:JORDAN, MITZI BUNCH (LCSWA)
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:BUNCH
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 SAPPHIRE CT STE 110
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-9079
Mailing Address - Country:US
Mailing Address - Phone:252-830-7540
Mailing Address - Fax:252-413-0932
Practice Address - Street 1:1141 N ROAD ST STE L
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3354
Practice Address - Country:US
Practice Address - Phone:252-335-0803
Practice Address - Fax:252-413-0932
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0113851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP011385OtherLCSWA LICENSURE