Provider Demographics
NPI:1174652598
Name:VIX, JORDAN DUNYASHA (MSW/LCSW)
Entity Type:Individual
Prefix:MS
First Name:JORDAN
Middle Name:DUNYASHA
Last Name:VIX
Suffix:
Gender:F
Credentials:MSW/LCSW
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:DUNYASHA
Other - Last Name:DUNYASHA/SHANAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2010 W AVENUE K # 389
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-5229
Mailing Address - Country:US
Mailing Address - Phone:661-974-8417
Mailing Address - Fax:661-729-2186
Practice Address - Street 1:349A E AVENUE K6
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4548
Practice Address - Country:US
Practice Address - Phone:661-974-8400
Practice Address - Fax:661-729-2186
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20718104100000X
CA258641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA159510OtherIS SVX LOC #
CAW2983OtherMEDICARE GROUP
CAHI557ZOtherPTAN
CA164501Medicare PIN