Provider Demographics
NPI:1639521461
Name:JORDAN, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
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 1:3877 12TH ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3578
Mailing Address - Country:US
Mailing Address - Phone:951-247-6064
Mailing Address - Fax:951-384-4696
Practice Address - Street 1:3877 12TH ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3578
Practice Address - Country:US
Practice Address - Phone:951-247-6064
Practice Address - Fax:951-384-4696
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist