Healthcare Provider Details

I. General information

NPI: 1316672595
Provider Name (Legal Business Name): JORDAN PHILLIP WATERS REGISTERED APCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2022
Last Update Date: 08/30/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W BRIGGSMORE AVE
MODESTO CA
95350-3839
US

IV. Provider business mailing address

2000 W BRIGGSMORE AVE
MODESTO CA
95350-3839
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-1440
  • Fax:
Mailing address:
  • Phone: 209-679-3114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: