Provider Demographics
NPI:1750856134
Name:JORDAN, CHANTEL ALEXUS
Entity Type:Individual
Prefix:
First Name:CHANTEL
Middle Name:ALEXUS
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 1:7191 17TH ST N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5405
Mailing Address - Country:US
Mailing Address - Phone:651-235-7232
Mailing Address - Fax:
Practice Address - Street 1:5201 BRYANT AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55430-3588
Practice Address - Country:US
Practice Address - Phone:612-284-8115
Practice Address - Fax:763-273-8892
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program