Provider Demographics
NPI:1740753771
Name:JORDAN, CHRISTINE (LPT)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40970 CAVALIER DR
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-6208
Mailing Address - Country:US
Mailing Address - Phone:951-400-6028
Mailing Address - Fax:
Practice Address - Street 1:40970 CAVALIER DR
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-6208
Practice Address - Country:US
Practice Address - Phone:951-400-6028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24408167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA24408OtherPSYCHIATRIC TECHNICIAN