Provider Demographics
NPI:1306127246
Name:PELOT, JORDAN GABRIEL (MA, LMFT)
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:GABRIEL
Last Name:PELOT
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3943
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-0943
Mailing Address - Country:US
Mailing Address - Phone:510-698-2579
Mailing Address - Fax:
Practice Address - Street 1:2901 SHATTUCK AVE
Practice Address - Street 2:SUITE E.
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1808
Practice Address - Country:US
Practice Address - Phone:510-698-2579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93693106H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist