Provider Demographics
NPI:1609315662
Name:LITVAK, JORDAN JAY (LICENSED CLINICAL SO)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:JAY
Last Name:LITVAK
Suffix:
Gender:M
Credentials:LICENSED CLINICAL SO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 BOYSENBERRY LN APT 2
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-5403
Mailing Address - Country:US
Mailing Address - Phone:217-971-8836
Mailing Address - Fax:
Practice Address - Street 1:2200 BOYSENBERRY LN APT 2
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-5403
Practice Address - Country:US
Practice Address - Phone:217-971-8836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-102921041C0700X
IL149-0036931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical