Provider Demographics
NPI:1902462799
Name:LEDDY, JORDAN ZY
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ZY
Last Name:LEDDY
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 1:85 RAMONA EXPY STE 1
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-7014
Mailing Address - Country:US
Mailing Address - Phone:951-349-4195
Mailing Address - Fax:
Practice Address - Street 1:85 RAMONA EXPY STE 1
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-7014
Practice Address - Country:US
Practice Address - Phone:951-349-4195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-16
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CA4721101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional