Provider Demographics
NPI:1316367048
Name:JORDAN, THOMAS W
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:JORDAN
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 1:16402 W RAINBOW RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-2527
Mailing Address - Country:US
Mailing Address - Phone:651-808-3926
Mailing Address - Fax:
Practice Address - Street 1:10594 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-6658
Practice Address - Country:US
Practice Address - Phone:715-934-1381
Practice Address - Fax:715-934-2091
Is Sole Proprietor?:No
Enumeration Date:2014-04-21
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WI1085-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health