Provider Demographics
NPI:1689251670
Name:WILKINSON, JORDAN ELIZABETH (RADT-I)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ELIZABETH
Last Name:WILKINSON
Suffix:
Gender:F
Credentials:RADT-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 HILBORN RD STE 950
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-7999
Mailing Address - Country:US
Mailing Address - Phone:707-639-1138
Mailing Address - Fax:
Practice Address - Street 1:3700 HILBORN RD STE 950
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-7999
Practice Address - Country:US
Practice Address - Phone:707-639-1138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 171M00000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1689251670OtherNPPES