Provider Demographics
NPI:1619590155
Name:OTTENBACHER, JORDAN THOMAS
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:THOMAS
Last Name:OTTENBACHER
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 1:227 NW SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-1746
Mailing Address - Country:US
Mailing Address - Phone:515-964-5003
Mailing Address - Fax:
Practice Address - Street 1:227 NW SCHOOL ST
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-1746
Practice Address - Country:US
Practice Address - Phone:515-964-5003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty