Provider Demographics
NPI:1043804560
Name:CASSEY, JORDON
Entity type:Individual
Prefix:MR
First Name:JORDON
Middle Name:
Last Name:CASSEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1367 SANTA DIANA RD UNIT 4
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-2741
Mailing Address - Country:US
Mailing Address - Phone:619-379-4295
Mailing Address - Fax:
Practice Address - Street 1:1367 SANTA DIANA RD UNIT 4
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-2741
Practice Address - Country:US
Practice Address - Phone:619-379-4295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY7805401172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver