Healthcare Provider Details

I. General information

NPI: 1144302803
Provider Name (Legal Business Name): WILLIAM J JORDAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

839 S PUTNAM ST
WILLIAMSTON MI
48895-1623
US

IV. Provider business mailing address

5525 S MARTIN LUTHER KING JR BLVD
LANSING MI
48911-3546
US

V. Phone/Fax

Practice location:
  • Phone: 517-655-3515
  • Fax: 855-476-0189
Mailing address:
  • Phone: 517-394-3175
  • Fax: 517-394-7453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001389
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: