Healthcare Provider Details

I. General information

NPI: 1295463917
Provider Name (Legal Business Name): MILES CRISTIANO JORDAN MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 24TH ST APT 1
SAN FRANCISCO CA
94110-3564
US

IV. Provider business mailing address

8945 GOLF LINKS RD
OAKLAND CA
94605-4124
US

V. Phone/Fax

Practice location:
  • Phone: 707-684-1069
  • Fax:
Mailing address:
  • Phone: 402-677-0388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: