Provider Demographics
NPI:1700676749
Name:FASH, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:FASH
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 1:737 18TH ST APT 9
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-1031
Mailing Address - Country:US
Mailing Address - Phone:319-621-8387
Mailing Address - Fax:
Practice Address - Street 1:1319 PENNSYLVANIA AVENUE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316
Practice Address - Country:US
Practice Address - Phone:515-241-0982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA131972101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health