=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407907405
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ESRA M JORDAN LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 FOLSOM RD SUITE C
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95678-2767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-284-5527
-----------------------------------------------------
Fax | 916-373-0304
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2443 FAIR OAKS BLVD #213
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825-7684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-284-5527
-----------------------------------------------------
Fax | 916-373-0304
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 41019
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------