Healthcare Provider Details

I. General information

NPI: 1104170729
Provider Name (Legal Business Name): BRANDY L JORDAN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 W LONG LAKE RD
BLOOMFIELD HILLS MI
48304-2769
US

IV. Provider business mailing address

1650 COLE ST
BIRMINGHAM MI
48009-7055
US

V. Phone/Fax

Practice location:
  • Phone: 248-496-3439
  • Fax:
Mailing address:
  • Phone: 248-496-3439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801073663
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: