Provider Demographics
NPI:1295009439
Name:JORDAN, REGINALD (MS, LPC, MAC, CPCS,)
Entity Type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MS, LPC, MAC, CPCS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E WASHINGTON ST UNIT D
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-1921
Mailing Address - Country:US
Mailing Address - Phone:404-277-8084
Mailing Address - Fax:678-550-9539
Practice Address - Street 1:30 E WASHINGTON ST UNIT D
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1921
Practice Address - Country:US
Practice Address - Phone:404-277-8084
Practice Address - Fax:678-550-9539
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007705101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional