Provider Demographics
NPI:1700401767
Name:ESTEBAN, JORDAN CLARK
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:CLARK
Last Name:ESTEBAN
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 1:704 E OSBORNE ESTATE CIR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8259
Mailing Address - Country:US
Mailing Address - Phone:801-669-7908
Mailing Address - Fax:
Practice Address - Street 1:440 S 500 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2705
Practice Address - Country:US
Practice Address - Phone:801-359-8862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11788173-3506104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker