Provider Demographics
NPI:1851712566
Name:KOLLER, JORDANA (LMSW)
Entity Type:Individual
Prefix:
First Name:JORDANA
Middle Name:
Last Name:KOLLER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 WALCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6311
Mailing Address - Country:US
Mailing Address - Phone:718-231-3400
Mailing Address - Fax:
Practice Address - Street 1:750 TILDEN STREET
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-6013
Practice Address - Country:US
Practice Address - Phone:718-231-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-23
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY088973104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY088973OtherASWB