=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902182025
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. JORDAN KAEHLER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2011
-----------------------------------------------------
Last Update Date | 01/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4550 N CLARENDON AVE APT. 702 S
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-6166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-295-4296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 N. KENSINGTON AVE
-----------------------------------------------------
City | LA GRANGE PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-965-2997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------