MEDICARE: KYSHEANNA RENEE JORDAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1225969777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYSHEANNA RENEE JORDAN

Provider Business Mailing Address
First Line	:	707 N ELM ST
Second Line	:
City	:	CHADBOURN
State	:	NC
Zip	:	28431-1508
Country	:	US
Telephone Number	:	910-625-0678
Fax Number	:

Provider Business Practice Location Address
First Line	:	707 N ELM ST
Second Line	:
City	:	CHADBOURN
State	:	NC
Zip	:	28431-1508
Country	:	US
Telephone Number	:	910-625-0678
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2026
Last Update Date	:	05/26/2026

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Directions to “ KYSHEANNA RENEE JORDAN ” Practice Location

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