Provider Demographics
NPI:1477037851
Name:SMITH, JORDAN K
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:K
Last Name:SMITH
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 1:912 NE KELLY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5631
Mailing Address - Country:US
Mailing Address - Phone:503-912-5502
Mailing Address - Fax:
Practice Address - Street 1:912 NE KELLY AVE STE 100
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5631
Practice Address - Country:US
Practice Address - Phone:503-912-5502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician