Provider Demographics
NPI:1083442123
Name:RICCOBONI, JORDAN (MPA)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:RICCOBONI
Suffix:
Gender:
Credentials:MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17575 YUKON AVE APT K4
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-3445
Mailing Address - Country:US
Mailing Address - Phone:559-708-3105
Mailing Address - Fax:
Practice Address - Street 1:1334 N AVALON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-2639
Practice Address - Country:US
Practice Address - Phone:310-835-4009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant