1881193134 NPI number — JORDAN MOSS SLP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881193134 NPI number — JORDAN MOSS SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOSS
Provider First Name:
JORDAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HALSETH
Provider Other First Name:
JORDAN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881193134
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58206-6000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-746-2205
Provider Business Mailing Address Fax Number:
701-787-4354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 47TH AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-746-2205
Provider Business Practice Location Address Fax Number:
701-787-4354
Provider Enumeration Date:
02/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 1618 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1474088 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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