=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790555639
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN HIGGINS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2024
-----------------------------------------------------
Last Update Date | 09/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5025 COLLWOOD BLVD # 2414
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92115-2126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-261-2237
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5025 COLLWOOD BLVD # 2414
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92115-2126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-261-2237
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 148636
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------