Provider Demographics
NPI:1679218564
Name:JORDAN, ANGELIA DENISE
Entity Type:Individual
Prefix:
First Name:ANGELIA
Middle Name:DENISE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-2360
Mailing Address - Country:US
Mailing Address - Phone:314-206-3700
Mailing Address - Fax:
Practice Address - Street 1:6763 PAGE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63133-1635
Practice Address - Country:US
Practice Address - Phone:314-320-6728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)