Provider Demographics
NPI:1962015495
Name:MEGLES, JORDAN TARA MARIE (BA, IIS, DSP, RBT)
Entity Type:Individual
Prefix:
First Name:JORDAN TARA
Middle Name:MARIE
Last Name:MEGLES
Suffix:
Gender:F
Credentials:BA, IIS, DSP, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 S FOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-7205
Mailing Address - Country:US
Mailing Address - Phone:913-940-0597
Mailing Address - Fax:
Practice Address - Street 1:1337 S FOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-7205
Practice Address - Country:US
Practice Address - Phone:913-940-0597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANEFE92EA405300000X
KSBACB478372106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No405300000XOther Service ProvidersPrevention Professional