Healthcare Provider Details

I. General information

NPI: 1225324247
Provider Name (Legal Business Name): JORDAN ALLEN M.S, L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 06/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 CABLE ST SUITE 'B'
SAN DIEGO CA
92107-3141
US

IV. Provider business mailing address

1804 CABLE ST SUITE 'B'
SAN DIEGO CA
92107-3141
US

V. Phone/Fax

Practice location:
  • Phone: 619-243-5109
  • Fax: 619-243-5113
Mailing address:
  • Phone: 619-243-5109
  • Fax: 619-243-5113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number12322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: