Provider Demographics
NPI:1821613969
Name:WOHLGEFAHRT, JORDYN KRIS
Entity Type:Individual
Prefix:
First Name:JORDYN
Middle Name:KRIS
Last Name:WOHLGEFAHRT
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 1:12464 PINEHURST CT
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-7678
Mailing Address - Country:US
Mailing Address - Phone:414-242-8342
Mailing Address - Fax:
Practice Address - Street 1:9230 OLD LORRAINE RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-6059
Practice Address - Country:US
Practice Address - Phone:228-731-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRBT-20-121919106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician