Provider Demographics
NPI:1396095006
Name:FLETCHER, JORDAN WILDMAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:WILDMAN
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:ELIZABETH
Other - Last Name:WILDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-1328
Mailing Address - Country:US
Mailing Address - Phone:970-335-2342
Mailing Address - Fax:
Practice Address - Street 1:1125 THREE SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-9033
Practice Address - Country:US
Practice Address - Phone:970-403-0180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
COLPC.0013032101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor