=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578216644
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN KIMBILLEE SPILLER PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2022
-----------------------------------------------------
Last Update Date | 01/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29255 NORTHWESTERN HWY STE 300
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-5742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-353-1234
-----------------------------------------------------
Fax | 248-353-1211
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24666 HAYMOW DR
-----------------------------------------------------
City | SOUTH LYON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48178-8290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-567-9050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501021641
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------