Provider Demographics
NPI:1649592510
Name:CORDOVA, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:CORDOVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 VIA ATHENA
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1606
Mailing Address - Country:US
Mailing Address - Phone:949-378-4615
Mailing Address - Fax:
Practice Address - Street 1:5 MAREBLU
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3014
Practice Address - Country:US
Practice Address - Phone:949-643-6974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health