Provider Demographics
NPI:1245528744
Name:NIVENS, JORDAN M
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:M
Last Name:NIVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 STATESVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-1411
Mailing Address - Country:US
Mailing Address - Phone:704-633-3616
Mailing Address - Fax:
Practice Address - Street 1:220 E. FIRST AVE. EXTENSION
Practice Address - Street 2:SUITE 10
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-3318
Practice Address - Country:US
Practice Address - Phone:336-242-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0083761041C0700X
NC2837-A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)