1831792159 NPI number — JORDAN FERRARI CRANDAL LSCSW

Table of content: JORDAN FERRARI CRANDAL LSCSW (NPI 1831792159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831792159 NPI number — JORDAN FERRARI CRANDAL LSCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRANDAL
Provider First Name:
JORDAN
Provider Middle Name:
FERRARI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LSCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FERRARI
Provider Other First Name:
JORDAN
Provider Other Middle Name:
SHARMAINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1831792159
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12062 SGT QUINN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79908-3250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-412-2048
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
590 MEDICAL CENTER ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT CAVAZOS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-288-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/19/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  11642 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 06199 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)