Provider Demographics
NPI:1225480619
Name:PANTHER, JORDAN ISAIAH
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:ISAIAH
Last Name:PANTHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:AUMSVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97325-8954
Mailing Address - Country:US
Mailing Address - Phone:503-510-7872
Mailing Address - Fax:
Practice Address - Street 1:4455 NE HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-9695
Practice Address - Country:US
Practice Address - Phone:541-758-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst