Healthcare Provider Details

I. General information

NPI: 1356790851
Provider Name (Legal Business Name): JORDAN MAXWELL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 S CREASY LN
LAFAYETTE IN
47905-4972
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 765-502-4780
  • Fax:
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5101022569
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number5101025758
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number02007042A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: