Provider Demographics
NPI:1811610983
Name:JORDAN WAKEFIELD, PLLC
Entity type:Organization
Organization Name:JORDAN WAKEFIELD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAKEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, LPC
Authorized Official - Phone:720-773-2026
Mailing Address - Street 1:PO BOX 12650
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80212-0650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:312-277-3846
Practice Address - Street 1:3434 W 29TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-3612
Practice Address - Country:US
Practice Address - Phone:720-773-2026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180.012130OtherPROFESSIONAL LICENSE