Provider Demographics
NPI:1750689337
Name:CARLSON, JORDAN DAVID (LPC)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:DAVID
Last Name:CARLSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:682 W BOUGHTON RD
Mailing Address - Street 2:UNIT D
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-5700
Mailing Address - Country:US
Mailing Address - Phone:630-771-0144
Mailing Address - Fax:630-771-9520
Practice Address - Street 1:682 W BOUGHTON RD
Practice Address - Street 2:UNIT D
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-5700
Practice Address - Country:US
Practice Address - Phone:630-771-0144
Practice Address - Fax:630-771-9520
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.007206101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health