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Mike Jordan
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Pueblo, Colorado
NPI 1790153039

Mike Jordan is a Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility based in Pueblo, CO. Mike Jordan practices in Pueblo, CO. The NPI Number for Mike Jordan is 1790153039 and holds a License No. (Colorado).

The current practice location address for Mike Jordan is 2928 Withers Ave, Pueblo, CO and can be reached out via phone at 719-543-8178 and via fax at 719-545-8583.

Location: 2928 Withers Ave, Pueblo, CO, 81008-8477
Profile Details Legacy Identifiers Practice Address Mailing Address Primary Taxonomy
person
Provider Profile Details
NPI Number
1790153039
Provider Name
Mike Jordan
Credential
Provider Entity Type
Individual
Gender
Male
Address
2928 Withers Ave, Pueblo, CO, 81008-8477
Phone Number
719-543-8178
Fax Number
719-545-8583
Provider Enumeration Date
09/03/2015
Last Update Date
03/09/2024
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Provider's Legacy Identifiers
Identifier Type State Issuer
47835346 05 CO
institution
Provider Business Practice Location Address Details
Address
2928 Withers Ave
City
Pueblo
State
Colorado
Zip
81008-1248
Phone Number
719-543-8178
Fax Number
719-545-8583
person
Provider Business Mailing Address Details
Address
2928 Withers Ave
City
Pueblo
State
Colorado
Zip
81008-1248
Phone Number
719-543-8178
Fax Number
719-545-8583
person
Provider's Taxonomy Details 1
Type
Residential Treatment Facilities
Classification
Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Speciality
-
Taxonomy
320900000X
License No.
()
Definition
A home-like residential facility providing habilitation, support and monitoring services to individuals diagnosed with intellectual and/or developmental disabilities.
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