Provider Demographics
NPI:1871022657
Name:JORDAN, DAVID JOSEPH
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOSEPH
Last Name:JORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:JOSEPH
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1903 BATAAN RD APT 12
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-1316
Mailing Address - Country:US
Mailing Address - Phone:310-606-1140
Mailing Address - Fax:
Practice Address - Street 1:1903 BATAAN RD APT 12
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-1316
Practice Address - Country:US
Practice Address - Phone:310-606-1140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48198225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA48198OtherMASSAGE THERAPY