Provider Demographics
NPI:1023659182
Name:JORDAN, THERESA ANN (LPT41449)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:JORDAN
Suffix:
Gender:F
Credentials:LPT41449
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 EASTBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95835-1348
Mailing Address - Country:US
Mailing Address - Phone:916-335-8641
Mailing Address - Fax:
Practice Address - Street 1:6950 65TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2316
Practice Address - Country:US
Practice Address - Phone:916-393-1222
Practice Address - Fax:916-393-4512
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41449167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician