Provider Demographics
NPI:1639616592
Name:PANGALLO-KOPROWSKI, JORDAN (LPCC, LICDC, LPC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:PANGALLO-KOPROWSKI
Suffix:
Gender:F
Credentials:LPCC, LICDC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-2348
Mailing Address - Country:US
Mailing Address - Phone:513-834-0763
Mailing Address - Fax:513-873-1567
Practice Address - Street 1:111 S BEDFORD ST STE 205
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-5145
Practice Address - Country:US
Practice Address - Phone:888-858-1723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161566101YA0400X
101YM0800X
OHE.1700245101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health