Provider Demographics
NPI:1588446496
Name:JORDAN, WESLEY
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:JORDAN
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 1:4891 GLOVER LN
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-4556
Mailing Address - Country:US
Mailing Address - Phone:850-626-0606
Mailing Address - Fax:850-361-3443
Practice Address - Street 1:5345 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1529
Practice Address - Country:US
Practice Address - Phone:850-463-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician