Provider Demographics
NPI:1841789195
Name:JORDAN, TREVOR DAVIS
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:DAVIS
Last Name:JORDAN
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 1:206 WOODLAND PKWY UNIT 128
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-6412
Mailing Address - Country:US
Mailing Address - Phone:707-303-5582
Mailing Address - Fax:
Practice Address - Street 1:800 E OHIO AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3421
Practice Address - Country:US
Practice Address - Phone:760-747-1275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CA32837235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst