Provider Demographics
NPI:1497593800
Name:JORDAN, MADISON ANN
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:ANN
Last Name:JORDAN
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 1:2461 S GILMOUR ST
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-7086
Mailing Address - Country:US
Mailing Address - Phone:435-703-5201
Mailing Address - Fax:
Practice Address - Street 1:2909 WASHINGTON BLVD STE 214
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-3744
Practice Address - Country:US
Practice Address - Phone:435-703-5201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty