Provider Demographics
NPI:1790453074
Name:JORDAN, TYLER BROOKE (LPCA)
Entity Type:Individual
Prefix:MRS
First Name:TYLER
Middle Name:BROOKE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 AVENUE OF THE PARK
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-7634
Mailing Address - Country:US
Mailing Address - Phone:601-941-7092
Mailing Address - Fax:
Practice Address - Street 1:4505 LUCKY STRIKE LOOP
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-7766
Practice Address - Country:US
Practice Address - Phone:270-240-4892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY270015101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional