Provider Demographics
NPI:1790054708
Name:JORDAN, PHILLIP LANDON
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:LANDON
Last Name:JORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1894
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:1430 WILLOW LN
Practice Address - Street 2:WESTPARK C61-2 N
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3551
Practice Address - Country:US
Practice Address - Phone:704-939-1100
Practice Address - Fax:704-939-1173
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9051101YP2500X
NCA9051101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor