Provider Demographics
NPI:1528438769
Name:JORDAN, NICOLE MICHELLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name: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 1:101 LADERA DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-5210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 41ST AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-3906
Practice Address - Country:US
Practice Address - Phone:831-737-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA358061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912278003OtherDEPARTMENT OF VETERANS AFFAIRS