Individual
JORDAN PORTNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
634 N MAIN ST STE 3, O FALLON, IL 62269-3746
(618) 632-4222
Mailing address
634 N MAIN ST STE 3, O FALLON, IL 62269-3746
(618) 632-4222
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
242006237
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
242.006237
PROFESSIONAL LICENSE
IL
Enumeration date
01/28/2022
Last updated
02/09/2022
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