Provider Demographics
NPI:1679064984
Name:DEWITT, JORDAN TYLER (MA, LMFT, LCAS)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:TYLER
Last Name:DEWITT
Suffix:
Gender:M
Credentials:MA, LMFT, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 JONES SPRINGS CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:ELLERBE
Mailing Address - State:NC
Mailing Address - Zip Code:28338-8413
Mailing Address - Country:US
Mailing Address - Phone:910-318-7416
Mailing Address - Fax:
Practice Address - Street 1:651 JONES SPRINGS CHURCH RD
Practice Address - Street 2:
Practice Address - City:ELLERBE
Practice Address - State:NC
Practice Address - Zip Code:28338-8413
Practice Address - Country:US
Practice Address - Phone:910-318-7416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-24343101YA0400X
NC12093A106H00000X
NC2160106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)