Provider Demographics
NPI:1033390570
Name:JORDAN, ROOSEVELT J
Entity type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:J
Last Name:JORDAN
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 1:588 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-7011
Mailing Address - Country:US
Mailing Address - Phone:510-252-0910
Mailing Address - Fax:
Practice Address - Street 1:588 BROWN RD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-7011
Practice Address - Country:US
Practice Address - Phone:510-252-0910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker