Provider Demographics
NPI:1093171480
Name:BLAINE, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BLAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 E CHAPMAN AVE UNIT 103
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-4140
Mailing Address - Country:US
Mailing Address - Phone:323-365-6312
Mailing Address - Fax:
Practice Address - Street 1:4900 E CHAPMAN AVE UNIT 103
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-4140
Practice Address - Country:US
Practice Address - Phone:323-365-6312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2020-05-06
Deactivation Date:2020-04-30
Deactivation Code:
Reactivation Date:2020-05-06
Provider Licenses
StateLicense IDTaxonomies
CA95014481363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health