Provider Demographics
NPI:1750042354
Name:WILLINGHAM, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WILLINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 ENERGY DRIVE
Mailing Address - Street 2:BUILDING #9
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2311 ENERGY DRIVE
Practice Address - Street 2:BUILDING #9
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502
Practice Address - Country:US
Practice Address - Phone:919-589-4523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician