Provider Demographics
NPI:1821640087
Name:DAVIS, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:DAVIS
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 1:420 S HENRY ST
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-4515
Mailing Address - Country:US
Mailing Address - Phone:605-223-1510
Mailing Address - Fax:605-494-1501
Practice Address - Street 1:357 KANSAS AVE SE
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-2517
Practice Address - Country:US
Practice Address - Phone:605-352-8596
Practice Address - Fax:605-352-7001
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health