MEDICARE: ANDREA JORDAN

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
1	164W00000X	Licensed Practical Nurse	4703063848	MI

General Provider Information

NPI Number	:	1790169035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA JORDAN

Provider Business Mailing Address
First Line	:	8945 NORTH PARK PLACE
Second Line	:	APT. 307
City	:	MILWAUKEE
State	:	WI
Zip	:	53223
Country	:	US
Telephone Number	:	248-667-1997
Fax Number	:

Provider Business Practice Location Address
First Line	:	9008 BURT RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48228-1610
Country	:	US
Telephone Number	:	248-667-1997
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2015
Last Update Date	:	07/16/2015

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Directions to “ ANDREA JORDAN ” Practice Location

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