Provider Demographics
NPI:1316533607
Name:PEREZ JORDAN, LUIS MANUEL
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:MANUEL
Last Name:PEREZ 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 1:3172 SW 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-3130
Mailing Address - Country:US
Mailing Address - Phone:786-953-3033
Mailing Address - Fax:
Practice Address - Street 1:3172 SW 24TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-3130
Practice Address - Country:US
Practice Address - Phone:786-953-3033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-129666106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician