Provider Demographics
NPI:1770943987
Name:JORDAN, LISA ELLEN (LCPC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ELLEN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5205
Mailing Address - Country:US
Mailing Address - Phone:847-638-2419
Mailing Address - Fax:
Practice Address - Street 1:420 LAKE COOK RD
Practice Address - Street 2:SUITE 121
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5646
Practice Address - Country:US
Practice Address - Phone:847-668-4295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-01
Last Update Date:2016-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180010147101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional