Provider Demographics
NPI:1225464779
Name:JORDAN, BRIANISHA MARIA
Entity Type:Individual
Prefix:
First Name:BRIANISHA
Middle Name:MARIA
Last Name:JORDAN
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 1:5185 CAMINO AL NORTE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-2415
Mailing Address - Country:US
Mailing Address - Phone:702-600-9433
Mailing Address - Fax:
Practice Address - Street 1:5185 CAMINO AL NORTE
Practice Address - Street 2:SUITE 120
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-2415
Practice Address - Country:US
Practice Address - Phone:702-600-9433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1404690171Medicaid