Provider Demographics
NPI:1235972340
Name:WISCHHUSEN, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WISCHHUSEN
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 1:21 MID PL
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-1903
Mailing Address - Country:US
Mailing Address - Phone:631-459-0919
Mailing Address - Fax:
Practice Address - Street 1:314 BRAMLETT BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-3459
Practice Address - Country:US
Practice Address - Phone:631-459-0919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program