Provider Demographics
NPI:1518742188
Name:WESTFALL, JORDAN (LPC-IT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WESTFALL
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 GLENPARK DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-6913
Mailing Address - Country:US
Mailing Address - Phone:920-676-4500
Mailing Address - Fax:
Practice Address - Street 1:926 WILLARD DR STE 126
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5071
Practice Address - Country:US
Practice Address - Phone:920-461-5820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7611-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional