Provider Demographics
NPI:1417592510
Name:ANDRUS, JORDAN K
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:K
Last Name:ANDRUS
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 1:11903 NE 116TH ST UNIT D70
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-2267
Mailing Address - Country:US
Mailing Address - Phone:360-831-5356
Mailing Address - Fax:
Practice Address - Street 1:9901 NE 7TH AVE # 116
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-4523
Practice Address - Country:US
Practice Address - Phone:360-571-2432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician