Provider Demographics
NPI:1689303026
Name:JORDAN, BRIAN KEITH (LMSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:JORDAN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2802 CONNECTICUT AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1913
Mailing Address - Country:US
Mailing Address - Phone:631-902-2481
Mailing Address - Fax:
Practice Address - Street 1:300 CENTER DR FL 2
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-3393
Practice Address - Country:US
Practice Address - Phone:631-852-2680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1053721104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker