Provider Demographics
NPI:1366989030
Name:GRANATA, JORDAN JOSEPH
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:JOSEPH
Last Name:GRANATA
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 1:2577 NE COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7752
Mailing Address - Country:US
Mailing Address - Phone:541-322-7500
Mailing Address - Fax:541-322-7565
Practice Address - Street 1:63311 JAMISON ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-8288
Practice Address - Country:US
Practice Address - Phone:541-322-7500
Practice Address - Fax:541-322-7565
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program