Provider Demographics
NPI:1194396036
Name:PEROUTKY, JORDAN CHRISTINE (SLP)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:CHRISTINE
Last Name:PEROUTKY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:JODRAN
Other - Middle Name:CHRISTINE
Other - Last Name:WHIPPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:100 COUNTY ROAD B
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-7072
Mailing Address - Country:US
Mailing Address - Phone:715-526-7370
Mailing Address - Fax:715-526-7294
Practice Address - Street 1:725 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3500
Practice Address - Country:US
Practice Address - Phone:920-433-7995
Practice Address - Fax:920-433-3458
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5258-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist