Provider Demographics
NPI:1962901041
Name:SWAN, STEPHANIE JORDAN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JORDAN
Last Name:SWAN
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 1:210 CREST RD
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 CREST RD
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:CA
Practice Address - Zip Code:94062-2311
Practice Address - Country:US
Practice Address - Phone:650-787-4483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer