Provider Demographics
NPI:1407143613
Name:SHIN, JORDAN J (MS)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:J
Last Name:SHIN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:J
Other - Last Name:SHIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:132 E BROADWAY STE 318
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3154
Mailing Address - Country:US
Mailing Address - Phone:541-342-8144
Mailing Address - Fax:541-342-7124
Practice Address - Street 1:132 E BROADWAY STE 318
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3154
Practice Address - Country:US
Practice Address - Phone:541-342-8144
Practice Address - Fax:541-342-1724
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-08
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2690101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional