Healthcare Provider Details

I. General information

NPI: 1104247170
Provider Name (Legal Business Name): DESIREE JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2013
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2527 GLEBE AVE
BRONX NY
10461-3109
US

IV. Provider business mailing address

2527 GLEBE AVE
BRONX NY
10461-3109
US

V. Phone/Fax

Practice location:
  • Phone: 718-904-4400
  • Fax: 718-904-7054
Mailing address:
  • Phone: 718-904-4400
  • Fax: 718-904-7054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number072551-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: