Basic Information
| Provider Information | |||||||||
| NPI: | 1801380654 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | TRE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19853 OUTER DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481242044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134065056 | ||||||||
| FaxNumber: | 2487124381 | ||||||||
| Practice Location | |||||||||
| Address1: | 19853 OUTER DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481242044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134065056 | ||||||||
| FaxNumber: | 2487124381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2018 | ||||||||
| LastUpdateDate: | 06/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 247200000X | MI | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.