Provider Demographics
NPI:1568145308
Name:THEPSOURINTHONE, JORDAN NICOLE (LISW)
Entity Type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:NICOLE
Last Name:THEPSOURINTHONE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 BRODYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-4584
Mailing Address - Country:US
Mailing Address - Phone:419-215-7762
Mailing Address - Fax:
Practice Address - Street 1:2121 HUGHES DR STE 640
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-5131
Practice Address - Country:US
Practice Address - Phone:419-291-3960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.23046641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical