Provider Demographics
NPI:1407062268
Name:JORDAN, JACQUELYN HARDY (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:HARDY
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 S SEMORAN BLVD STE 1150
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-5505
Mailing Address - Country:US
Mailing Address - Phone:321-972-1875
Mailing Address - Fax:407-315-0048
Practice Address - Street 1:7275 MINIPPI DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-8250
Practice Address - Country:US
Practice Address - Phone:407-619-0737
Practice Address - Fax:407-295-1014
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13890101YM0800X, 171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL762506500Medicaid