1295938132 NPI number — MRS. RACHEL MARIE JORDAN MSW, QMHP

Table of content: MRS. RACHEL MARIE JORDAN MSW, QMHP (NPI 1295938132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295938132 NPI number — MRS. RACHEL MARIE JORDAN MSW, QMHP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JORDAN
Provider First Name:
RACHEL
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, QMHP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YORK
Provider Other First Name:
RACHEL
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295938132
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 W BLUE BLAZE TRL
Provider Second Line Business Mailing Address:
LOT F9
Provider Business Mailing Address City Name:
HERRIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62948-6419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-925-4122
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 E VINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIENNA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62995-1612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-658-2611
Provider Business Practice Location Address Fax Number:
618-658-2501
Provider Enumeration Date:
06/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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