Provider Demographics
NPI:1457024739
Name:JORDAN, BROOKLYNNE PAIGE
Entity Type:Individual
Prefix:
First Name:BROOKLYNNE
Middle Name:PAIGE
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 1:2601 SE EMMETT RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5214
Mailing Address - Country:US
Mailing Address - Phone:239-233-5098
Mailing Address - Fax:
Practice Address - Street 1:10272 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5615
Practice Address - Country:US
Practice Address - Phone:772-872-6940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-01
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician