Healthcare Provider Details

I. General information

NPI: 1548091770
Provider Name (Legal Business Name): JORDAN AGUILERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2836 W JEFFERSON AVE
TRENTON MI
48183-2902
US

IV. Provider business mailing address

9170 BYROMAR LN
GROSSE ILE MI
48138-1203
US

V. Phone/Fax

Practice location:
  • Phone: 734-301-5748
  • Fax:
Mailing address:
  • Phone: 734-558-6086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362010207
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: