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General NPI Number Information
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NPI Number | 1508602087
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Entity Type | Individual
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Provider Name | GEANCARLO ISRAEL JORDAN MHC-LP
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Gender | Male
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Dates
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Enumeration Date | 07/03/2024
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Last Update Date | 07/03/2024
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Provider Practice Location Address
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Address Line | 303 5TH AVE RM 1503
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City | NEW YORK
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State | NY
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Zip | 10016-6666
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Country | US
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Telephone | 646-359-4345
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Fax |
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Provider Business Mailing Address
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Address Line | 1416 WYTHE PL APT 1A
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City | BRONX
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State | NY
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Zip | 10452-6921
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Country | US
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Telephone | 646-359-4345
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 18-P118246-01
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License Number State | NY
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