Basic Information
| Provider Information | |||||||||
| NPI: | 1225265986 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | SHAVONDA | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, PLCSW,LCASA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIVERS | ||||||||
| OtherFirstName: | SHAVONDA | ||||||||
| OtherMiddleName: | DENISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW, LCASA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 215 N MAGNOLIA ST | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291514943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037759364 | ||||||||
| FaxNumber: | 8037736615 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 COMMERCE ST | ||||||||
| Address2: | |||||||||
| City: | MANNING | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291022638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034352124 | ||||||||
| FaxNumber: | 8034358113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2009 | ||||||||
| LastUpdateDate: | 10/29/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | P005024 | NC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | P005024 | NC | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | P005024 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.