Provider Demographics
NPI:1184080269
Name:ROSS, JORDANA (LAC)
Entity type:Individual
Prefix:
First Name:JORDANA
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 ALSCOT AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-3810
Mailing Address - Country:US
Mailing Address - Phone:805-231-4518
Mailing Address - Fax:
Practice Address - Street 1:15300 VENTURA BLVD
Practice Address - Street 2:SUITE NUMBER 315
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3103
Practice Address - Country:US
Practice Address - Phone:805-231-4518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16932171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist