Provider Demographics
NPI:1356862841
Name:HARGRAVE, JORDYN
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:
Last Name:HARGRAVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JORDYN
Other - Middle Name:
Other - Last Name:JASPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4801 WELDON SPRING PKWY
Mailing Address - Street 2:
Mailing Address - City:WELDON SPRING
Mailing Address - State:MO
Mailing Address - Zip Code:63304-9101
Mailing Address - Country:US
Mailing Address - Phone:636-441-7300
Mailing Address - Fax:
Practice Address - Street 1:4801 WELDON SPRING PKWY
Practice Address - Street 2:
Practice Address - City:WELDON SPRING
Practice Address - State:MO
Practice Address - Zip Code:63304-9101
Practice Address - Country:US
Practice Address - Phone:636-441-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020023093103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst