Provider Demographics
NPI:1831572072
Name:JORDAN, JUDITH (LCSW)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1696
Mailing Address - Street 2:
Mailing Address - City:AMAGANSETT
Mailing Address - State:NY
Mailing Address - Zip Code:11930-1696
Mailing Address - Country:US
Mailing Address - Phone:917-825-4905
Mailing Address - Fax:
Practice Address - Street 1:9 N MAIN ST
Practice Address - Street 2:#8
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937-2632
Practice Address - Country:US
Practice Address - Phone:917-825-4905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY077715-1101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)