Healthcare Provider Details

I. General information

NPI: 1669469094
Provider Name (Legal Business Name): JORDAN KIELISZEWSKI LISWS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 09/22/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 N PERIMETER RD
MALMSTROM AFB MT
59402-6701
US

IV. Provider business mailing address

7300 N PERIMETER RD
MALMSTROM AFB MT
59402-6701
US

V. Phone/Fax

Practice location:
  • Phone: 64-731-4494
  • Fax:
Mailing address:
  • Phone: 406-731-3219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS32150
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: