Provider Demographics
NPI:1942974050
Name:WILBORN, JORDAN ISIAH ANTHONY
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ISIAH ANTHONY
Last Name:WILBORN
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 1:2640 INDUSTRY WAY
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-4284
Mailing Address - Country:US
Mailing Address - Phone:310-627-4525
Mailing Address - Fax:310-945-3356
Practice Address - Street 1:2640 INDUSTRY WAY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-4284
Practice Address - Country:US
Practice Address - Phone:310-627-4525
Practice Address - Fax:310-945-3356
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA42594167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner