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General NPI Number Information
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NPI Number | 1558105726
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Entity Type | Individual
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Provider Name | JORDAN DAVID BRYANT PMHNP-BC
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Gender | Male
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Dates
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Enumeration Date | 06/22/2024
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Last Update Date | 06/22/2024
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Provider Practice Location Address
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Address Line | 5555 CONNER ST STE 3
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City | DETROIT
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State | MI
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Zip | 48213-3448
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Country | US
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Telephone | 313-344-7730
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Fax |
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Provider Business Mailing Address
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Address Line | 18987 PINE CONE DR
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City | MACOMB
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State | MI
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Zip | 48042-4212
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Country | US
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Telephone | 586-231-4861
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 4704327810
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License Number State | MI
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