Provider Demographics
NPI:1205306917
Name:JORDAN, ROXANNE (AOD CERTIFICATION)
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:AOD CERTIFICATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 PORTER AVE
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-2743
Mailing Address - Country:US
Mailing Address - Phone:818-916-8574
Mailing Address - Fax:
Practice Address - Street 1:1050 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3802
Practice Address - Country:US
Practice Address - Phone:909-623-6391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)