Healthcare Provider Details

I. General information

NPI: 1285348797
Provider Name (Legal Business Name): DIANTE SCOTT JORDAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 FARVIEW TER STE 1
PARAMUS NJ
07652-2762
US

IV. Provider business mailing address

15 FARVIEW TER STE 1
PARAMUS NJ
07652-2762
US

V. Phone/Fax

Practice location:
  • Phone: 551-579-4441
  • Fax:
Mailing address:
  • Phone: 551-579-4441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37FA00032700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: