Healthcare Provider Details

I. General information

NPI: 1467007021
Provider Name (Legal Business Name): JORDAN WIDNER AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10021 DUPONT CIRCLE CT
FORT WAYNE IN
46825-1604
US

IV. Provider business mailing address

10021 DUPONT CIRCLE CT
FORT WAYNE IN
46825-1604
US

V. Phone/Fax

Practice location:
  • Phone: 260-426-8117
  • Fax: 260-420-0817
Mailing address:
  • Phone: 260-426-8117
  • Fax: 260-420-0817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA.02163
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number23002789A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: