Provider Demographics
NPI:1730761370
Name:PUCCINELLI, JORDAN CHRISTIAN (LPCC MED)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:CHRISTIAN
Last Name:PUCCINELLI
Suffix:
Gender:M
Credentials:LPCC MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6255 W RIVER RD S
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-5433
Mailing Address - Country:US
Mailing Address - Phone:440-420-0033
Mailing Address - Fax:
Practice Address - Street 1:202 E BAGLEY RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-2058
Practice Address - Country:US
Practice Address - Phone:440-260-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2025-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X, 172V00000X
OHE.2505015101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker