Provider Demographics
NPI:1770199820
Name:LILLARD, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:LILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4717 MORTENSEN RD UNIT 103
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50014-6219
Mailing Address - Country:US
Mailing Address - Phone:515-423-3323
Mailing Address - Fax:
Practice Address - Street 1:1315 S BELL AVE STE 108
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-7730
Practice Address - Country:US
Practice Address - Phone:515-337-0343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2022-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
IA114642103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-22-61281OtherBEHAVIOR ANALYST CERTIFICATION BOARD
IA114642OtherSTATE BOARD OF BEHAVIORAL SCIENCE