Provider Demographics
NPI:1811886195
Name:JORDAN, KELLI MICHELLE (LCAS-A)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:MICHELLE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:597 N FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-2726
Mailing Address - Country:US
Mailing Address - Phone:336-416-9571
Mailing Address - Fax:
Practice Address - Street 1:1001 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3245
Practice Address - Country:US
Practice Address - Phone:336-721-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-01
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30985101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)