Provider Demographics
NPI:1285487447
Name:THRALL, JORDYN RAEANN
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:RAEANN
Last Name:THRALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 W ROSE ST APT 21
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-1672
Mailing Address - Country:US
Mailing Address - Phone:509-956-1105
Mailing Address - Fax:
Practice Address - Street 1:106 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3001
Practice Address - Country:US
Practice Address - Phone:509-956-1105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician