Provider Demographics
NPI:1639616592
Name:PANGALLO, JORDAN (LPCC, LICDC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:PANGALLO
Suffix:
Gender:F
Credentials:LPCC, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-2348
Mailing Address - Country:US
Mailing Address - Phone:513-834-0763
Mailing Address - Fax:513-873-1567
Practice Address - Street 1:1100 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:OH
Practice Address - Zip Code:45103-1920
Practice Address - Country:US
Practice Address - Phone:513-834-0763
Practice Address - Fax:513-873-1567
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1700245101YP2500X
101YM0800X
OHLICDC.161566101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)