=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639615321
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN DANIEL STRICKLEN PSYD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2017
-----------------------------------------------------
Last Update Date | 07/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 833 KENMOOR AVE SE STE A
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-2390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-551-4690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 509 HARTFIELD DR SE
-----------------------------------------------------
City | ADA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49301-7707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-401-6578
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 6351004119
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6301018878
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------