Provider Demographics
NPI:1538737101
Name:WINES, JORDAN (AUD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:WINES
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E WATAUGA AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-4628
Mailing Address - Country:US
Mailing Address - Phone:423-928-5771
Mailing Address - Fax:423-928-1424
Practice Address - Street 1:106 E WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4628
Practice Address - Country:US
Practice Address - Phone:423-928-5771
Practice Address - Fax:423-928-1424
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2091231H00000X
NC14980231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14980OtherAUDIOLOGY LICENSURE
TNQ076394Medicaid