Provider Demographics
NPI:1801634290
Name:HOLMAN, JORDAN R
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:R
Last Name:HOLMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69730 HIGHWAY 111 STE 109
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-2873
Mailing Address - Country:US
Mailing Address - Phone:760-322-1777
Mailing Address - Fax:
Practice Address - Street 1:69730 HIGHWAY 111 STE 109
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-2873
Practice Address - Country:US
Practice Address - Phone:760-322-1777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1519030823101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)