Provider Demographics
NPI:1861364200
Name:FRAGEN, JORDAN SOPHIE
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:SOPHIE
Last Name:FRAGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 AVENUE OF THE STARS FL 8
Mailing Address - Street 2:
Mailing Address - City:CENTURY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90067-5010
Mailing Address - Country:US
Mailing Address - Phone:310-853-3311
Mailing Address - Fax:
Practice Address - Street 1:2121 AVENUE OF THE STARS FL 8
Practice Address - Street 2:
Practice Address - City:CENTURY CITY
Practice Address - State:CA
Practice Address - Zip Code:90067-5010
Practice Address - Country:US
Practice Address - Phone:310-853-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist