Provider Demographics
NPI:1063105013
Name:MILLETTE, JORDAN OLUSHEGUN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:OLUSHEGUN
Last Name:MILLETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 NANCI CT
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6036
Mailing Address - Country:US
Mailing Address - Phone:470-230-1043
Mailing Address - Fax:
Practice Address - Street 1:109 NANCI CT
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6036
Practice Address - Country:US
Practice Address - Phone:470-230-1043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABACB80315106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician