Healthcare Provider Details

I. General information

NPI: 1346731296
Provider Name (Legal Business Name): JOURDAN BRADSHAW GARD DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2018
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11012 E 13 MILE RD STE 112
WARREN MI
48093-2546
US

IV. Provider business mailing address

2399 ELLWOOD AVE
BERKLEY MI
48072-1048
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-6880
  • Fax:
Mailing address:
  • Phone: 325-665-8380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number5101027918
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101023987
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: