Provider Demographics
NPI:1669469094
Name:KIELISZEWSKI, JORDAN (LISWS)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:KIELISZEWSKI
Suffix:
Gender:M
Credentials:LISWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 N PERIMETER RD
Mailing Address - Street 2:
Mailing Address - City:MALMSTROM AFB
Mailing Address - State:MT
Mailing Address - Zip Code:59402-6701
Mailing Address - Country:US
Mailing Address - Phone:406-731-3219
Mailing Address - Fax:
Practice Address - Street 1:7300 N PERIMETER RD
Practice Address - Street 2:
Practice Address - City:MALMSTROM AFB
Practice Address - State:MT
Practice Address - Zip Code:59402-6701
Practice Address - Country:US
Practice Address - Phone:064-731-4494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS321501041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical