Provider Demographics
NPI:1003261116
Name:PEIXOTO, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:PEIXOTO
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 1:445 MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-5007
Mailing Address - Country:US
Mailing Address - Phone:631-827-1948
Mailing Address - Fax:
Practice Address - Street 1:445 MEADOW RD
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-5007
Practice Address - Country:US
Practice Address - Phone:631-827-1948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator