Healthcare Provider Details

I. General information

NPI: 1205570561
Provider Name (Legal Business Name): JORDAN CHANDLER WALKER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 07/29/2024
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 32ND ST SE
GRAND RAPIDS MI
49508-7910
US

IV. Provider business mailing address

25 MICHIGAN ST NE STE 2100
GRAND RAPIDS MI
49503-2526
US

V. Phone/Fax

Practice location:
  • Phone: 164-525-9006
  • Fax:
Mailing address:
  • Phone: 616-391-3777
  • Fax: 616-391-3755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number5101028180
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: