Provider Demographics
NPI:1730643008
Name:OSTERMILLER, JORDON R
Entity Type:Individual
Prefix:
First Name:JORDON
Middle Name:R
Last Name:OSTERMILLER
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 1:242 E 7TH N STE 4
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-3550
Mailing Address - Country:US
Mailing Address - Phone:208-359-9683
Mailing Address - Fax:
Practice Address - Street 1:242 E 7TH N STE 4
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-3550
Practice Address - Country:US
Practice Address - Phone:208-359-9683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-38314104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1639292626Medicaid