Basic Information
| Provider Information | |||||||||
| NPI: | 1467802561 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | DEVONEIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10244 ARROW RTE | ||||||||
| Address2: | #54 | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917304785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513122085 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2085 RUSTIN AVE | ||||||||
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| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925072498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519557263 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2016 | ||||||||
| LastUpdateDate: | 06/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.