Provider Demographics
NPI:1467042879
Name:VAN DE VERE, JORDAN MICHAEL (C PED)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MICHAEL
Last Name:VAN DE VERE
Suffix:
Gender:M
Credentials:C PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9901 N CAPITAL OF TEXAS HWY STE 120
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5853
Mailing Address - Country:US
Mailing Address - Phone:512-346-4400
Mailing Address - Fax:512-346-3009
Practice Address - Street 1:4615 N LAMAR BLVD STE 305
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-2357
Practice Address - Country:US
Practice Address - Phone:512-476-5110
Practice Address - Fax:512-476-5178
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist