Provider Demographics
NPI:1588274021
Name:SUDDUTH-JORDAN, LUCRETIA NAVELLE
Entity type:Individual
Prefix:
First Name:LUCRETIA
Middle Name:NAVELLE
Last Name:SUDDUTH-JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29217 EDEN SHORES DR
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-1356
Mailing Address - Country:US
Mailing Address - Phone:510-919-3158
Mailing Address - Fax:
Practice Address - Street 1:29217 EDEN SHORES DR
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-1356
Practice Address - Country:US
Practice Address - Phone:510-919-3158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27561225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist