Provider Demographics
NPI:1316252513
Name:JORDAN, JENNIFER M (PSYD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 PACIFIC COAST HWY
Mailing Address - Street 2:SUITE 209
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-2757
Mailing Address - Country:US
Mailing Address - Phone:310-698-2185
Mailing Address - Fax:
Practice Address - Street 1:2200 PACIFIC COAST HWY
Practice Address - Street 2:SUITE 209
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2757
Practice Address - Country:US
Practice Address - Phone:310-698-2185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 225400000X
CAPSY26915103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY26915OtherLICENSE NUMBER
CAPSY26915OtherLICENSE NUMBER