Provider Demographics
NPI:1184461345
Name:NICKEL-DUBIN, JORDAN TAYLOR (MA)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:TAYLOR
Last Name:NICKEL-DUBIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 SW SALMON ST APT 409
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-3845
Mailing Address - Country:US
Mailing Address - Phone:818-635-3808
Mailing Address - Fax:
Practice Address - Street 1:811 NW 19TH AVE # 301
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1401
Practice Address - Country:US
Practice Address - Phone:503-866-0299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-13
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101200000XBehavioral Health & Social Service ProvidersDrama Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional