Provider Demographics
NPI:1518008713
Name:JORDAN, CAROLYN LILLIAN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:LILLIAN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1187 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02019-1500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 WHITMAN RD
Practice Address - Street 2:CLARKE SCHOOL EAST
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-2707
Practice Address - Country:US
Practice Address - Phone:781-821-3499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
308946171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator