Provider Demographics
NPI:1396361515
Name:JORDAN, LOURIE M (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:LOURIE
Middle Name:M
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8616 PORTOLA RD
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-5478
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10333 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-5808
Practice Address - Country:US
Practice Address - Phone:805-468-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018952363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty