Provider Demographics
NPI:1649319724
Name:DENYSE, ROBERT JORDAN (MA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JORDAN
Last Name:DENYSE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 W WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-3605
Mailing Address - Country:US
Mailing Address - Phone:260-426-3409
Mailing Address - Fax:260-426-0302
Practice Address - Street 1:217 W WAYNE ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-3605
Practice Address - Country:US
Practice Address - Phone:260-426-3409
Practice Address - Fax:260-426-0302
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002372A231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter