Provider Demographics
NPI:1588158794
Name:JORDAN, NICOLE (BCABA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 MIDDLE ST UNIT 1201
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3625
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:407-588-6294
Practice Address - Street 1:6976 PROFESSIONAL PKWY E
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34240
Practice Address - Country:US
Practice Address - Phone:941-308-4641
Practice Address - Fax:941-342-6189
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-18-8907106E00000X
106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst