Provider Demographics
NPI:1184651002
Name:JORDAN, ROSALIE ADAM (MA RN LPCC)
Entity Type:Individual
Prefix:MRS
First Name:ROSALIE
Middle Name:ADAM
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MA RN LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 OSUNA RD NE STE H4
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5955
Mailing Address - Country:US
Mailing Address - Phone:505-345-2778
Mailing Address - Fax:505-345-2878
Practice Address - Street 1:320 OSUNA RD NE STE H4
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5955
Practice Address - Country:US
Practice Address - Phone:505-345-2778
Practice Address - Fax:505-345-2878
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0106101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18593OtherPHP
NMNM100011OtherVALUE OP