Provider Demographics
NPI:1083611701
Name:JORDAN, MARY K (LICSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1952 FISCHER DR
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-7501
Mailing Address - Country:US
Mailing Address - Phone:952-442-2191
Mailing Address - Fax:952-442-6044
Practice Address - Street 1:500 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1752
Practice Address - Country:US
Practice Address - Phone:952-442-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13949104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker