Provider Demographics
NPI:1780195198
Name:EDWARDS, JORDAN WESLEY (PHD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:WESLEY
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 ENCINA RD STE A
Mailing Address - Street 2:
Mailing Address - City:GOLETA
Mailing Address - State:CA
Mailing Address - Zip Code:93117-2270
Mailing Address - Country:US
Mailing Address - Phone:805-681-0035
Mailing Address - Fax:805-681-0029
Practice Address - Street 1:5901 ENCINA RD STE A
Practice Address - Street 2:
Practice Address - City:GOLETA
Practice Address - State:CA
Practice Address - Zip Code:93117-2270
Practice Address - Country:US
Practice Address - Phone:805-681-0035
Practice Address - Fax:805-681-0029
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-12
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29531103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist