Healthcare Provider Details

I. General information

NPI: 1811774037
Provider Name (Legal Business Name): JORDAN NICOLE BEACH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N CLYBOURN AVE UNIT C105
CHICAGO IL
60610-2295
US

IV. Provider business mailing address

34755 COUNTY ROAD 10
KEENESBURG CO
80643-8526
US

V. Phone/Fax

Practice location:
  • Phone: 312-242-1665
  • Fax:
Mailing address:
  • Phone: 970-381-2869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-78117
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberA.B.61477567
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberCBT.CB.61472697
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: