Provider Demographics
NPI:1427544766
Name:MANTOOTH-JORDAN, ISAIAH RAPHEAL (THERAPIST)
Entity Type:Individual
Prefix:
First Name:ISAIAH
Middle Name:RAPHEAL
Last Name:MANTOOTH-JORDAN
Suffix:
Gender:F
Credentials:THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 OLD FALLS ST STE 3B
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14303-1262
Mailing Address - Country:US
Mailing Address - Phone:716-300-8339
Mailing Address - Fax:
Practice Address - Street 1:225 OLD FALLS ST STE 3B
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14303-1262
Practice Address - Country:US
Practice Address - Phone:716-300-8339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health