Provider Demographics
NPI:1245109487
Name:JORDAN, KATHERINE TAYLOR (MED)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:TAYLOR
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 SPRING OAK RD UNIT 1122
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-7554
Mailing Address - Country:US
Mailing Address - Phone:805-861-4874
Mailing Address - Fax:
Practice Address - Street 1:644 SPRING OAK RD UNIT 1122
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-7554
Practice Address - Country:US
Practice Address - Phone:805-861-4874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-04
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-22-238143106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician