Provider Demographics
NPI:1417834615
Name:MADISON, JORDAN (LAC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:MADISON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PITCAIRN AVE
Mailing Address - Street 2:
Mailing Address - City:HO HO KUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07423-1622
Mailing Address - Country:US
Mailing Address - Phone:201-820-7380
Mailing Address - Fax:
Practice Address - Street 1:140 E RIDGEWOOD AVE STE 415
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3915
Practice Address - Country:US
Practice Address - Phone:201-820-7380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-19
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00902800101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health