Provider Demographics
NPI:1396484291
Name:HARTLEY, JORDYN J-M
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:J-M
Last Name:HARTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:J-M
Other - Last Name:HARTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:638 1/2 W CORNELIA AVE APT 3E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2510
Mailing Address - Country:US
Mailing Address - Phone:831-854-7524
Mailing Address - Fax:
Practice Address - Street 1:1409 W CARROLL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1105
Practice Address - Country:US
Practice Address - Phone:312-733-0883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician