Provider Demographics
NPI:1336471630
Name:JORDAN-CHURCH, MARY E (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:JORDAN-CHURCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4735 E SIMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-1662
Mailing Address - Country:US
Mailing Address - Phone:559-251-0148
Mailing Address - Fax:
Practice Address - Street 1:4735 E SIMPSON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-1662
Practice Address - Country:US
Practice Address - Phone:559-251-0148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-11
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 240681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical