Provider Demographics
NPI:1124211826
Name:JON VAN DOREN, PH.D., PLLC
Entity Type:Organization
Organization Name:JON VAN DOREN, PH.D., PLLC
Other - Org Name:VAN DOREN NEUROPSYCHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-699-6968
Mailing Address - Street 1:10613 N HAYDEN RD STE J108
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-5576
Mailing Address - Country:US
Mailing Address - Phone:480-699-6968
Mailing Address - Fax:480-666-4803
Practice Address - Street 1:10613 N HAYDEN RD STE J108
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-5576
Practice Address - Country:US
Practice Address - Phone:480-699-6968
Practice Address - Fax:480-666-4803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-26
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2081103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1114072220OtherNPI
20166Medicare PIN
60231Medicare PIN