Provider Demographics
NPI:1902330483
Name:JORDAN, ELIZABETH (MMSC, CGC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MMSC, CGC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:SCHMITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:460 W 12TH AVE RM 339
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-2210
Mailing Address - Country:US
Mailing Address - Phone:614-366-3597
Mailing Address - Fax:614-688-1381
Practice Address - Street 1:452 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-293-7677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00000170300000X
OH70.000283170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCS1719300252Medicaid