Provider Demographics
NPI:1265077812
Name:KOEGLE, JORDAN (LISW)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:KOEGLE
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3964 HAMILTON SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-9119
Mailing Address - Country:US
Mailing Address - Phone:614-610-1506
Mailing Address - Fax:614-834-8694
Practice Address - Street 1:3964 HAMILTON SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-9119
Practice Address - Country:US
Practice Address - Phone:614-610-1506
Practice Address - Fax:614-834-8694
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1600951104100000X
OHI21027531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker