Healthcare Provider Details

I. General information

NPI: 1649319724
Provider Name (Legal Business Name): ROBERT JORDAN DENYSE M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 W WAYNE ST
FORT WAYNE IN
46802-3605
US

IV. Provider business mailing address

217 W WAYNE ST
FORT WAYNE IN
46802-3605
US

V. Phone/Fax

Practice location:
  • Phone: 260-426-3409
  • Fax: 260-426-0302
Mailing address:
  • Phone: 260-426-3409
  • Fax: 260-426-0302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number23002372A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number23002372A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: