Healthcare Provider Details

I. General information

NPI: 1376352294
Provider Name (Legal Business Name): CORTEZ TRENTON JORDAN LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15600 19 MILE RD
CLINTON TOWNSHIP MI
48038-3502
US

IV. Provider business mailing address

9654 GRANDMONT AVE
DETROIT MI
48227-1073
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-8700
  • Fax:
Mailing address:
  • Phone: 313-221-0729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451024079
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: