1790107563 NPI number — MRS. JORDAN L CARLL LISW-CP-S, MPH

Table of content: MRS. JORDAN L CARLL LISW-CP-S, MPH (NPI 1790107563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790107563 NPI number — MRS. JORDAN L CARLL LISW-CP-S, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLL
Provider First Name:
JORDAN
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LISW-CP-S, MPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROWN
Provider Other First Name:
JORDAN
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790107563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
140 STONERIDGE DR
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29210-8200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-779-5500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 STONERIDGE DR
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29210-8200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-779-5500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/14/2014

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 10508 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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