Provider Demographics
NPI:1326695495
Name:WAN, JORDAN (MT, TAI NA)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:WAN
Suffix:
Gender:M
Credentials:MT, TAI NA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 SMITH LANE STE #3
Mailing Address - Street 2:STE #3
Mailing Address - City:ROSEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:95661-4123
Mailing Address - Country:US
Mailing Address - Phone:916-783-3003
Mailing Address - Fax:916-783-4799
Practice Address - Street 1:1141 SMITH LANE STE #3
Practice Address - Street 2:STE #3
Practice Address - City:ROSEVILLE
Practice Address - State:OH
Practice Address - Zip Code:95661-4123
Practice Address - Country:US
Practice Address - Phone:916-783-3003
Practice Address - Fax:916-783-4799
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71847798225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist