Provider Demographics
NPI:1639641772
Name:SANTIAGO-STOUT, JORDONA
Entity Type:Individual
Prefix:
First Name:JORDONA
Middle Name:
Last Name:SANTIAGO-STOUT
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 1:14 CORTE LADO
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-2110
Mailing Address - Country:US
Mailing Address - Phone:925-497-3069
Mailing Address - Fax:
Practice Address - Street 1:559 16TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1515
Practice Address - Country:US
Practice Address - Phone:510-238-5091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional