1811054224 NPI number — MS. GLORY JORDAN LCSW, DCSW

Table of content: MS. GLORY JORDAN LCSW, DCSW (NPI 1811054224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811054224 NPI number — MS. GLORY JORDAN LCSW, DCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JORDAN
Provider First Name:
GLORY
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW, DCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FRIDDELL-JORDAN
Provider Other First Name:
GLORY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW, DCSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1811054224
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 TIFFANY PT
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
BLOOMINGDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60108-2936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-924-0600
Provider Business Mailing Address Fax Number:
630-206-3019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 TIFFANY PT
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
BLOOMINGDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60108-2936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-924-0600
Provider Business Practice Location Address Fax Number:
866-808-2485
Provider Enumeration Date:
01/03/2007

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: 1041C0700X , with the licence number:  149.002321 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 262945 . This is a "VALUE OPTIONS PROVIDER NO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 363716771 . This is a "TAX ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 7435198 . This is a "AETNA BEHAVORIAL HEALTH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 363716771 0012 . This is a "CIGNA BEHAVORIAL HEALTH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 2232789 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 476392000 . This is a "MAGELLAN HEALTH SERVICES" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 206554117 . This is a "UNITED BEH. HEALTH PROVID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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