Provider Demographics
NPI:1073744066
Name:JORDAN, NICHOLE (M COUN, LCPC, NCC)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:M COUN, LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 W AMERICANA TER
Mailing Address - Street 2:SUITE #215
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-2521
Mailing Address - Country:US
Mailing Address - Phone:208-342-7030
Mailing Address - Fax:208-342-7030
Practice Address - Street 1:3350 W AMERICANA TER
Practice Address - Street 2:SUITE #215
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2521
Practice Address - Country:US
Practice Address - Phone:208-342-7030
Practice Address - Fax:208-342-7030
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-07
Last Update Date:2011-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-4471101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional