Provider Demographics
NPI:1083303077
Name:PHELPS, JORDAN ASHLEY
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ASHLEY
Last Name:PHELPS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 S UTAH AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2531
Mailing Address - Country:US
Mailing Address - Phone:208-740-9194
Mailing Address - Fax:
Practice Address - Street 1:3729 KLINDT DR
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3566
Practice Address - Country:US
Practice Address - Phone:541-298-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist