Provider Demographics
NPI:1790577393
Name:JORDAN, KATIE RAY
Entity type:Individual
Prefix:MISS
First Name:KATIE
Middle Name:RAY
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KATIE
Other - Middle Name:RAY
Other - Last Name:PEGORER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:745 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-5081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 W LINE ST STE 4
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-1837
Practice Address - Country:US
Practice Address - Phone:678-383-0636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional