Healthcare Provider Details

I. General information

NPI: 1770292831
Provider Name (Legal Business Name): GEORGE JORDAN III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4892 SAN PABLO DAM RD
EL SOBRANTE CA
94803-3222
US

IV. Provider business mailing address

4892 SAN PABLO DAM RD
EL SOBRANTE CA
94803-3222
US

V. Phone/Fax

Practice location:
  • Phone: 510-223-4236
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberNPPES
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: