Provider Demographics
NPI:1508602087
Name:JORDAN, GEANCARLO ISRAEL (MHC-LP)
Entity type:Individual
Prefix:
First Name:GEANCARLO
Middle Name:ISRAEL
Last Name:JORDAN
Suffix:
Gender:M
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 WYTHE PL APT 1A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-6921
Mailing Address - Country:US
Mailing Address - Phone:646-359-4345
Mailing Address - Fax:
Practice Address - Street 1:303 5TH AVE RM 1503
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6666
Practice Address - Country:US
Practice Address - Phone:646-359-4345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18-P118246-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health