Healthcare Provider Details

I. General information

NPI: 1104739820
Provider Name (Legal Business Name): MICHELLE LYNN JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9627 PHILADELPHIA RD STE 160
ROSEDALE MD
21237-4157
US

IV. Provider business mailing address

9627 PHILADELPHIA RD STE 160
ROSEDALE MD
21237-4157
US

V. Phone/Fax

Practice location:
  • Phone: 410-780-5203
  • Fax: 414-780-5205
Mailing address:
  • Phone: 410-780-5203
  • Fax: 414-780-5205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number35195
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: