Healthcare Provider Details

I. General information

NPI: 1659824910
Provider Name (Legal Business Name): JORDAN JOHNSON BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1834 FIELDS BLVD
GREENFIELD IN
46140-3029
US

IV. Provider business mailing address

1834 FIELDS BLVD
GREENFIELD IN
46140-3029
US

V. Phone/Fax

Practice location:
  • Phone: 814-602-3287
  • Fax:
Mailing address:
  • Phone: 317-527-5437
  • Fax: 317-318-1356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-25355
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: