Provider Demographics
NPI:1376156661
Name:JORDAN, LAZORA
Entity Type:Individual
Prefix:
First Name:LAZORA
Middle Name:
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 1:106 S HARRISON ST APT 504
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-1729
Mailing Address - Country:US
Mailing Address - Phone:813-766-3732
Mailing Address - Fax:
Practice Address - Street 1:1824 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-3832
Practice Address - Country:US
Practice Address - Phone:212-423-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY110287104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker