Healthcare Provider Details

I. General information

NPI: 1669042578
Provider Name (Legal Business Name): JORDAN RAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5960 N MILWAUKEE AVE
CHICAGO IL
60646-5424
US

IV. Provider business mailing address

4123 W BELLE PLAINE AVE APT 19
CHICAGO IL
60641-2469
US

V. Phone/Fax

Practice location:
  • Phone: 224-243-4819
  • Fax:
Mailing address:
  • Phone: 801-691-8653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number152.003363
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: