Provider Demographics
NPI:1467050203
Name:WISNIEWSKI, JORDAN SCOTT (HIS)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:SCOTT
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4847 W. FOREST HOME AVENUE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53219
Mailing Address - Country:US
Mailing Address - Phone:414-321-2020
Mailing Address - Fax:414-321-3113
Practice Address - Street 1:4847 W. FOREST HOME AVENUE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53219
Practice Address - Country:US
Practice Address - Phone:414-321-2020
Practice Address - Fax:414-321-3113
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1400-60237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist