Provider Demographics
NPI:1134725799
Name:WHEALDON, JORDAN LEE (LSW)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEE
Last Name:WHEALDON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 W COLUMBIA AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-4581
Mailing Address - Country:US
Mailing Address - Phone:937-728-0225
Mailing Address - Fax:
Practice Address - Street 1:6417 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2437
Practice Address - Country:US
Practice Address - Phone:773-777-7112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150104805104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker