Provider Demographics
NPI:1396083366
Name:JORDAN, WESLEY WREN (MSJST)
Entity type:Individual
Prefix:MRS
First Name:WESLEY
Middle Name:WREN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MSJST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 NE 143RD AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-8113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9300 NE OAK VIEW DR
Practice Address - Street 2:SUITE B
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6157
Practice Address - Country:US
Practice Address - Phone:360-567-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60150462101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor