Provider Demographics
NPI:1588620827
Name:JORDAN, JILL ELAINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:ELAINE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1913
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-0913
Mailing Address - Country:US
Mailing Address - Phone:804-520-5859
Mailing Address - Fax:804-733-2070
Practice Address - Street 1:111 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-3139
Practice Address - Country:US
Practice Address - Phone:804-520-5859
Practice Address - Fax:804-733-2070
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040013061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00890285Medicaid
VA094480OtherANTHEM
VA542370OtherMAMSI
VA8000000605Medicare ID - Type Unspecified