Provider Demographics
NPI:1326521188
Name:CHAMBERLAIN, JORDAN (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:CHAMBERLAIN
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 COUNTRYSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-6101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 COUNTRYSIDE CIR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-6101
Practice Address - Country:US
Practice Address - Phone:801-618-6864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1-18-29457103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst