Provider Demographics
NPI:1942098660
Name:PARKER, JORDAN KEILAH
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:KEILAH
Last Name:PARKER
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 1:12263 W HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1433
Mailing Address - Country:US
Mailing Address - Phone:205-422-1969
Mailing Address - Fax:
Practice Address - Street 1:12263 W HICKORY DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1433
Practice Address - Country:US
Practice Address - Phone:205-422-1969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRBT-25-426805106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician