Provider Demographics
NPI:1316672595
Name:WATERS, JORDAN PHILLIP (REGISTERED APCC)
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:PHILLIP
Last Name:WATERS
Suffix:
Gender:M
Credentials:REGISTERED APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W BRIGGSMORE AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-3839
Mailing Address - Country:US
Mailing Address - Phone:209-679-3114
Mailing Address - Fax:
Practice Address - Street 1:2000 W BRIGGSMORE AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-3839
Practice Address - Country:US
Practice Address - Phone:209-526-1440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12233101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional