Provider Demographics
NPI:1417562208
Name:ACOSTA, JORDAN (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:SHIMAMURA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:25102 JEFFERSON AVE STE D
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-1708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25102 JEFFERSON AVE STE D
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-1708
Practice Address - Country:US
Practice Address - Phone:951-461-1190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22452235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist