Provider Demographics
NPI:1366949976
Name:CALABRESE, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:CALABRESE
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 1:20333 W 151ST ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-7211
Mailing Address - Country:US
Mailing Address - Phone:913-791-4200
Mailing Address - Fax:
Practice Address - Street 1:20333 W 151ST ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-5350
Practice Address - Country:US
Practice Address - Phone:913-791-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-466722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004824960002Medicaid