Provider Demographics
NPI:1255847786
Name:WISNER, JORDAN M (PHD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:M
Last Name:WISNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 W FORT ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4535
Mailing Address - Country:US
Mailing Address - Phone:208-422-1018
Mailing Address - Fax:
Practice Address - Street 1:444 W FORT ST FL 2
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4535
Practice Address - Country:US
Practice Address - Phone:208-422-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist