MEDICARE: JORDYN VAN

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	103K00000X	Behavior Analyst	486-140	WI

General Provider Information

NPI Number	:	1265183958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDYN VAN

Provider Business Mailing Address
First Line	:	1575 ALLOUEZ AVE
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-5639
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4005 FELLAND RD STE 102
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53718-6461
Country	:	US
Telephone Number	:	920-857-9041
Fax Number	:

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

Provider Enumeration Date	:	01/13/2022
Last Update Date	:	01/13/2022

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Directions to “ JORDYN VAN ” Practice Location

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