Provider Demographics
NPI:1467941997
Name:JORDAN, DANA ELISSE (LCDC II)
Entity Type:Individual
Prefix:MS
First Name:DANA
Middle Name:ELISSE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LCDC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 BECKMAN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45410-2165
Mailing Address - Country:US
Mailing Address - Phone:937-253-1680
Mailing Address - Fax:
Practice Address - Street 1:732 BECKMAN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-2165
Practice Address - Country:US
Practice Address - Phone:937-253-1680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161388101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$Medicaid