Provider Demographics
NPI:1770095119
Name:WILES, JORDAN KENT (SSP, NCSP)
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:KENT
Last Name:WILES
Suffix:
Gender:M
Credentials:SSP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 N MATTIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-2448
Mailing Address - Country:US
Mailing Address - Phone:618-919-0408
Mailing Address - Fax:
Practice Address - Street 1:807 N MATTIS AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-2448
Practice Address - Country:US
Practice Address - Phone:618-919-0408
Practice Address - Fax:618-919-0408
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool