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NPI Code Detail

MEDICARE: DR. MIRA CHARLOTTE JOURDAN PHD

MEDICARE: DR. MIRA CHARLOTTE JOURDAN PHD
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
1103G00000XClinical Neuropsychologist6301014267MI
2103TC0700XClinical Psychologist6301014267MI

General Provider Information

NPI Number : 1902194806
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MIRA CHARLOTTE JOURDAN PHD
Provider Business Mailing Address
First Line : 2626 BROOKLYN AVE SE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49507-3937
Country : US
Telephone Number : 248-885-4992
Fax Number : 616-825-6264
Provider Business Practice Location Address
First Line : 3361 36TH ST SE
Second Line :
City : KENTWOOD
State : MI
Zip : 49512-2809
Country : US
Telephone Number : 616-942-2522
Fax Number : 616-956-3260
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/13/2011
Last Update Date : 08/25/2021

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