Provider Demographics
NPI:1174150049
Name:FRENTRESS, JORDAN T (BC-HIS)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:T
Last Name:FRENTRESS
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11052 HICKMAN RD
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-3740
Mailing Address - Country:US
Mailing Address - Phone:515-278-2517
Mailing Address - Fax:
Practice Address - Street 1:11052 HICKMAN RD
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-3740
Practice Address - Country:US
Practice Address - Phone:515-278-2517
Practice Address - Fax:515-331-1400
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001085237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist