Provider Demographics
NPI:1790860294
Name:JORDAN, SCOTT (LCSW, CASAC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 THORN AVENUE BOX 631
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127
Mailing Address - Country:US
Mailing Address - Phone:716-662-2040
Mailing Address - Fax:716-662-0019
Practice Address - Street 1:1235 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-2111
Practice Address - Country:US
Practice Address - Phone:716-884-5797
Practice Address - Fax:716-884-4938
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11739101YA0400X
NY695961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000528699001OtherBCBS
NY000528699001OtherBCBS