Provider Demographics
NPI:1215396916
Name:JORDAN, MARISSA (LPC)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:27 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-2212
Mailing Address - Country:US
Mailing Address - Phone:423-573-6836
Mailing Address - Fax:423-388-4774
Practice Address - Street 1:268 CHRISTIAN CHURCH RD STE 2
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4484
Practice Address - Country:US
Practice Address - Phone:423-491-4202
Practice Address - Fax:423-388-4774
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1500150101YM0800X
TN4767101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health