Provider Demographics
NPI:1669911285
Name:JORDAN, DEREK R
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:R
Last Name:JORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6460 HARRISON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7958
Mailing Address - Country:US
Mailing Address - Phone:513-941-4999
Mailing Address - Fax:513-694-0168
Practice Address - Street 1:25 WHITNEY DR STE 122
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-8400
Practice Address - Country:US
Practice Address - Phone:513-941-4999
Practice Address - Fax:513-694-0168
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.121091101YA0400X
OHLICDC.161401101YA0400X
OHLCDCII.121091101YA0400X, 101YA0400X
OHC.1600018101YP2500X
OHE.2303715-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0218756Medicaid