Provider Demographics
NPI:1285348797
Name:JORDAN, DIANTE SCOTT
Entity type:Individual
Prefix:
First Name:DIANTE
Middle Name:SCOTT
Last Name:JORDAN
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 1:15 FARVIEW TER STE 1
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-2762
Mailing Address - Country:US
Mailing Address - Phone:551-579-4441
Mailing Address - Fax:
Practice Address - Street 1:15 FARVIEW TER STE 1
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2762
Practice Address - Country:US
Practice Address - Phone:551-579-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37FA00032700101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health