Basic Information
| Provider Information | |||||||||
| NPI: | 1720679541 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANDLISH | ||||||||
| FirstName: | JORDYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21600 OXNARD ST STE 1800 | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913677807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183452345 | ||||||||
| FaxNumber: | 0000000000 | ||||||||
| Practice Location | |||||||||
| Address1: | 334 VIA VERA CRUZ STE 107 | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920782637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603045010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2021 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 00014788 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.