Provider Demographics
NPI:1932673563
Name:DESIMONE, JORDAN T (CADC-CAS)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:T
Last Name:DESIMONE
Suffix:
Gender:M
Credentials:CADC-CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 PRIME CT
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-5035
Mailing Address - Country:US
Mailing Address - Phone:860-712-8128
Mailing Address - Fax:626-270-4640
Practice Address - Street 1:460 E SACRAMENTO ST
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-2915
Practice Address - Country:US
Practice Address - Phone:626-808-0335
Practice Address - Fax:626-270-4640
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC039991116101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC039991116OtherCALIFORNIA CONSORTIUM OF ADDICTION PROGRAMS AND PROFESSIONALS