Provider Demographics
NPI:1043515570
Name:JORDANICA INC
Entity Type:Organization
Organization Name:JORDANICA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:PREMSELAAR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:702-358-0464
Mailing Address - Street 1:780 CORONADO CENTER DR
Mailing Address - Street 2:SUITE 110A
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5040
Mailing Address - Country:US
Mailing Address - Phone:702-358-0464
Mailing Address - Fax:610-432-3508
Practice Address - Street 1:780 CORONADO CENTER DR
Practice Address - Street 2:SUITE 110A
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5040
Practice Address - Country:US
Practice Address - Phone:702-358-0464
Practice Address - Fax:610-432-3508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5782C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty