Provider Demographics
NPI:1568350080
Name:MOORE, JORDAN N
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:N
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4761 JESSIE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-8857
Mailing Address - Country:US
Mailing Address - Phone:408-960-5073
Mailing Address - Fax:
Practice Address - Street 1:1545 HOTEL CIR S STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3414
Practice Address - Country:US
Practice Address - Phone:619-549-0329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12366101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health