Healthcare Provider Details

I. General information

NPI: 1528677358
Provider Name (Legal Business Name): JORDAN CLINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N CLYBOURN AVE
CHICAGO IL
60610-3017
US

IV. Provider business mailing address

823 W BUENA AVE APT 306
CHICAGO IL
60613-1643
US

V. Phone/Fax

Practice location:
  • Phone: 312-242-1665
  • Fax:
Mailing address:
  • Phone: 941-223-1094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: