Provider Demographics
NPI:1477214559
Name:JORDAN, MIKIAVIDILIA SHARELLE YVONNE (N/A)
Entity Type:Individual
Prefix:MISS
First Name:MIKIAVIDILIA
Middle Name:SHARELLE YVONNE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:MISS
Other - First Name:KIA
Other - Middle Name:SY
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:N/A
Mailing Address - Street 1:18726 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3813
Mailing Address - Country:US
Mailing Address - Phone:310-856-0800
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:5400 W PLANO PKWY STE 200
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4855
Practice Address - Country:US
Practice Address - Phone:888-922-2843
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2021-12-31
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician