Basic Information
| Provider Information | |||||||||
| NPI: | 1225510944 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKAGGS | ||||||||
| FirstName: | JORDYN | ||||||||
| MiddleName: | DAKOTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3430 COGSWELL RD | ||||||||
| Address2: | |||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917322785 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 845 E ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096241233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2018 | ||||||||
| LastUpdateDate: | 06/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 85183 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.