Healthcare Provider Details

I. General information

NPI: 1710436001
Provider Name (Legal Business Name): JORDAN KO PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12544 HIGH BLUFF DR STE 200
SAN DIEGO CA
92130-3050
US

IV. Provider business mailing address

12544 HIGH BLUFF DR STE 200
SAN DIEGO CA
92130-3050
US

V. Phone/Fax

Practice location:
  • Phone: 858-215-2620
  • Fax:
Mailing address:
  • Phone: 858-215-2620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY32500
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: