Provider Demographics
NPI:1871611194
Name:WILSON JORDAN, PEGGY MARGARET (PHD, MFT, ATR)
Entity type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:MARGARET
Last Name:WILSON JORDAN
Suffix:
Gender:F
Credentials:PHD, MFT, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13561 RELIANCE ST
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-6334
Mailing Address - Country:US
Mailing Address - Phone:818-901-7166
Mailing Address - Fax:818-901-7166
Practice Address - Street 1:12450 VAN NUYS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1393
Practice Address - Country:US
Practice Address - Phone:818-896-1161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7068Medicaid
CA7420Medicaid