Basic Information
| Provider Information | |||||||||
| NPI: | 1609131549 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIEBE | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.A. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1841 FULTON ST STE B | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937211031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592887254 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3467 W SHAW AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937113223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592713096 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2012 | ||||||||
| LastUpdateDate: | 07/06/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.