Provider Demographics
NPI:1457423535
Name:MILLICENT C. JORDAN, LLC
Entity Type:Organization
Organization Name:MILLICENT C. JORDAN, LLC
Other - Org Name:ASHLEY THERAPY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MILLICENT
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:843-573-5050
Mailing Address - Street 1:1 CARRIAGE LN STE J
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-6060
Mailing Address - Country:US
Mailing Address - Phone:843-573-5050
Mailing Address - Fax:843-573-5030
Practice Address - Street 1:1 CARRIAGE LN STE J
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-6060
Practice Address - Country:US
Practice Address - Phone:843-573-5050
Practice Address - Fax:843-573-5030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC328103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC202569Medicaid