Provider Demographics
NPI:1447713557
Name:WOODRUFF, JORDAN KEVIN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:KEVIN
Last Name:WOODRUFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11715 S STATE ST APT E204
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-6910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11715 S STATE ST APT E204
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-6910
Practice Address - Country:US
Practice Address - Phone:208-965-4563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-15-2763-06274106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty