Provider Demographics
NPI:1447807227
Name:JORDAN, RYAN BAILEY (LMSW)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:BAILEY
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 DELTONA BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-8016
Mailing Address - Country:US
Mailing Address - Phone:386-259-5413
Mailing Address - Fax:
Practice Address - Street 1:111 E MONUMENT AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5762
Practice Address - Country:US
Practice Address - Phone:407-483-8953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-16920104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty