Provider Demographics
NPI:1407390396
Name:SMALLWOOD, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:SMALLWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 PITTSBURGH RD
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-8407
Mailing Address - Country:US
Mailing Address - Phone:724-912-6800
Mailing Address - Fax:724-550-4117
Practice Address - Street 1:1023 PITTSBURGH RD
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-8407
Practice Address - Country:US
Practice Address - Phone:724-912-6800
Practice Address - Fax:724-550-4117
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA30350195101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)