Provider Demographics
NPI:1881623197
Name:JORDAN, KATHY QUARLES (LCSW)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:QUARLES
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:P.O. BOX 6430
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72766
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:479-750-8967
Practice Address - Street 1:12 W. SUNBRIDGE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-750-2020
Practice Address - Fax:479-750-8967
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1573-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y996OtherBLUE SHIELD PROVIDER #