Provider Demographics
NPI:1376001792
Name:NILES, JORDAN ALEXANDER
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ALEXANDER
Last Name:NILES
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 1:333 NE 146TH AVE APT 210
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-4273
Mailing Address - Country:US
Mailing Address - Phone:503-753-3194
Mailing Address - Fax:
Practice Address - Street 1:805 SE 151ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-2916
Practice Address - Country:US
Practice Address - Phone:971-271-7270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1245624253171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator