Provider Demographics
NPI:1295579456
Name:KLOSE, JAIDEN
Entity type:Individual
Prefix:
First Name:JAIDEN
Middle Name:
Last Name:KLOSE
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 1:19216 ROCK POINTE WAY UNIT 204Q
Mailing Address - Street 2:
Mailing Address - City:LANNON
Mailing Address - State:WI
Mailing Address - Zip Code:53046-1230
Mailing Address - Country:US
Mailing Address - Phone:918-213-9877
Mailing Address - Fax:
Practice Address - Street 1:19216 ROCK POINTE WAY UNIT 204Q
Practice Address - Street 2:
Practice Address - City:LANNON
Practice Address - State:WI
Practice Address - Zip Code:53046-1230
Practice Address - Country:US
Practice Address - Phone:918-213-9877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-22
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist