Healthcare Provider Details

I. General information

NPI: 1144708447
Provider Name (Legal Business Name): JORDAN MARENDINO M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 11/15/2020
Certification Date: 11/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 BROOKHOLLOW DR STE 212
SANTA ANA CA
92705-5411
US

IV. Provider business mailing address

26431 PEBBLE CRK
LAKE FOREST CA
92630-5647
US

V. Phone/Fax

Practice location:
  • Phone: 949-242-9720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: