Provider Demographics
NPI:1558889212
Name:JORDAN, KIM YVETTE (LPCC-S)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:YVETTE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2018 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44146-2314
Mailing Address - Country:US
Mailing Address - Phone:216-246-9437
Mailing Address - Fax:
Practice Address - Street 1:2018 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:BEDFORD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44146-2314
Practice Address - Country:US
Practice Address - Phone:216-246-9437
Practice Address - Fax:216-250-8185
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-01
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1100473-S101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0249061Medicaid