Provider Demographics
NPI:1881193134
Name:MOSS, JORDAN (SLP)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:MOSS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:HALSETH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:PO BOX 6000
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-6000
Mailing Address - Country:US
Mailing Address - Phone:701-746-2205
Mailing Address - Fax:701-787-4354
Practice Address - Street 1:2400 47TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-746-2205
Practice Address - Fax:701-787-4354
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
ND1618235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1474088Medicaid