=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194324475
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN JARVIS BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2020
-----------------------------------------------------
Last Update Date | 09/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44670 ANN ARBOR RD W
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48170-3962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-278-4601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4530 E RAY RD STE 100
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85044-6095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-850-6665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 7401002274
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------