Provider Demographics
NPI:1053858399
Name:KOHNKE, JORDAN (BA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:KOHNKE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:6296 BRIDGEPORT VILLAGE SQUARE DR STE 2
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:MI
Mailing Address - Zip Code:48722-9655
Mailing Address - Country:US
Mailing Address - Phone:989-401-1239
Mailing Address - Fax:
Practice Address - Street 1:6296 BRIDGEPORT VILLAGE SQUARE DR STE 2
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:MI
Practice Address - Zip Code:48722-9655
Practice Address - Country:US
Practice Address - Phone:989-401-1239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician