Provider Demographics
NPI:1871103655
Name:VAN TRESS, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:VAN TRESS
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 1:12115 PRINCEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-3944
Mailing Address - Country:US
Mailing Address - Phone:317-752-4812
Mailing Address - Fax:
Practice Address - Street 1:12115 PRINCEWOOD CT
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-3944
Practice Address - Country:US
Practice Address - Phone:317-752-4812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN84000215A171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist