Provider Demographics
NPI:1760888184
Name:MAHAN, JORDAN KELSEY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:KELSEY
Last Name:MAHAN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 REMINGTON CV
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-8274
Mailing Address - Country:US
Mailing Address - Phone:501-850-8788
Mailing Address - Fax:
Practice Address - Street 1:5 REMINGTON CV
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-8274
Practice Address - Country:US
Practice Address - Phone:501-850-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-12
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP9191235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR222651721Medicaid