Provider Demographics
NPI:1508415134
Name:AMUNDSEN, JORDAN CASEY MANLEY
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:CASEY MANLEY
Last Name:AMUNDSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:CASEY
Other - Last Name:MANLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:120 S BARSTOW ST
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-3642
Mailing Address - Country:US
Mailing Address - Phone:877-967-5577
Mailing Address - Fax:
Practice Address - Street 1:120 S BARSTOW ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3642
Practice Address - Country:US
Practice Address - Phone:877-967-5577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4492-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional