Provider Demographics
NPI:1033881875
Name:DELAGRANGE, JORDAN MATTHEW (LMT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MATTHEW
Last Name:DELAGRANGE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2606 RIDGEWAY DR APT 3203
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-7772
Mailing Address - Country:US
Mailing Address - Phone:260-444-1159
Mailing Address - Fax:
Practice Address - Street 1:2801 CAMINO DEL RIO S STE 204-7
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3800
Practice Address - Country:US
Practice Address - Phone:260-444-1159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83253225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist