Provider Demographics
NPI:1578041794
Name:SPENCER, JORDAN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:2302 KENWOOD BLVD APT 4
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3781
Mailing Address - Country:US
Mailing Address - Phone:937-305-3441
Mailing Address - Fax:
Practice Address - Street 1:1104 WESLEY AVE
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-2579
Practice Address - Country:US
Practice Address - Phone:419-636-5071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND.2018728-SP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist