Provider Demographics
NPI:1073128294
Name:RICE, JORDAN ELIZABETH (CERTIFIED)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ELIZABETH
Last Name:RICE
Suffix:
Gender:F
Credentials:CERTIFIED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 ROBLE GRANDE RD
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-3024
Mailing Address - Country:US
Mailing Address - Phone:619-917-6249
Mailing Address - Fax:
Practice Address - Street 1:1717 ROBLE GRANDE RD
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-3024
Practice Address - Country:US
Practice Address - Phone:619-917-6249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72403225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist