=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629785639
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN MICHELLE DAYLOR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2022
-----------------------------------------------------
Last Update Date | 10/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 MUIR RD
-----------------------------------------------------
City | MARTINEZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94553-4668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-487-9784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 156 CORRAL CIR
-----------------------------------------------------
City | SAN RAMON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94583-2443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-487-9784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 0810007517
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 33690
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------