Provider Demographics
NPI:1467161190
Name:THIBODEAUX, JOURDAN PAIGE
Entity Type:Individual
Prefix:
First Name:JOURDAN
Middle Name:PAIGE
Last Name:THIBODEAUX
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 1:1275 E DATE ST APT 201
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4202
Mailing Address - Country:US
Mailing Address - Phone:909-246-7020
Mailing Address - Fax:
Practice Address - Street 1:100 UNIVERSAL CITY PLZ
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91608-1002
Practice Address - Country:US
Practice Address - Phone:909-246-7020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
12385087OtherKAISER