Provider Demographics
NPI:1548840507
Name:BENTLEY, JORDAN NICOLE (LCSW)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:NICOLE
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2807 AMBERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-4734
Mailing Address - Country:US
Mailing Address - Phone:217-415-3406
Mailing Address - Fax:
Practice Address - Street 1:2807 AMBERWOOD CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4734
Practice Address - Country:US
Practice Address - Phone:217-415-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490187001041C0700X
MO20210089241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical