Provider Demographics
NPI:1235528381
Name:KNUDSEN, JORDAN TAYLOR
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:TAYLOR
Last Name:KNUDSEN
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 1:1701 MISSION AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-7102
Mailing Address - Country:US
Mailing Address - Phone:262-498-2044
Mailing Address - Fax:
Practice Address - Street 1:1701 MISSION AVE
Practice Address - Street 2:SUITE A
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-7102
Practice Address - Country:US
Practice Address - Phone:262-498-2044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIK5324389263000390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program