Healthcare Provider Details

I. General information

NPI: 1477037851
Provider Name (Legal Business Name): JORDAN K SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 NE KELLY AVE STE 100
GRESHAM OR
97030-5631
US

IV. Provider business mailing address

912 NE KELLY AVE STE 100
GRESHAM OR
97030-5631
US

V. Phone/Fax

Practice location:
  • Phone: 503-912-5502
  • Fax:
Mailing address:
  • Phone: 503-912-5502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: