Provider Demographics
NPI:1124757745
Name:JORDAN RESIDENTIAL & VOCATIONAL SERVICES INC.
Entity type:Organization
Organization Name:JORDAN RESIDENTIAL & VOCATIONAL SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-251-4604
Mailing Address - Street 1:PO BOX 8477
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-8477
Mailing Address - Country:US
Mailing Address - Phone:719-251-4604
Mailing Address - Fax:719-545-8583
Practice Address - Street 1:2928 WITHERS AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1248
Practice Address - Country:US
Practice Address - Phone:719-543-8178
Practice Address - Fax:719-545-8583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities