Healthcare Provider Details

I. General information

NPI: 1689819278
Provider Name (Legal Business Name): MS. JORDEN NICHOLE WAVEREK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2008
Last Update Date: 12/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1756 S LEWIS RD
CAMARILLO CA
93012-8520
US

IV. Provider business mailing address

1339 NATHAN LN
VENTURA CA
93001-4010
US

V. Phone/Fax

Practice location:
  • Phone: 805-383-3669
  • Fax:
Mailing address:
  • Phone: 805-766-0809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: