Provider Demographics
NPI:1144944802
Name:DEVRIES, JORDAN ELAINE
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ELAINE
Last Name:DEVRIES
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 1:814 TYVOLA RD STE 126
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-3539
Mailing Address - Country:US
Mailing Address - Phone:980-785-1113
Mailing Address - Fax:980-758-1114
Practice Address - Street 1:815 OLD WINSTON RD STE 101
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7125
Practice Address - Country:US
Practice Address - Phone:980-785-1113
Practice Address - Fax:980-785-1114
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-22-61297103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst