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NPI Code Detail

MEDICARE: JORDAN ELIZABETH GARDNER OTRL

MEDICARE: JORDAN ELIZABETH GARDNER OTRL
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225X00000XOccupational Therapist5201009433MI

General Provider Information

NPI Number : 1073960472
Entity Type Code : Individual
Provider Name (Legal Business Name) : JORDAN ELIZABETH GARDNER OTRL
Provider Business Mailing Address
First Line : 3135 PROFESSIONAL DR
Second Line :
City : ANN ARBOR
State : MI
Zip : 48104-5131
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 30821 BARRINGTON ST
Second Line :
City : MADISON HEIGHTS
State : MI
Zip : 48071-1871
Country : US
Telephone Number : 248-291-5397
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/16/2016
Last Update Date : 05/23/2022

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