Provider Demographics
NPI:1003229246
Name:SMITH, JORDAN NATHANIEL (LLMFT)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:NATHANIEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 BALL AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5904
Mailing Address - Country:US
Mailing Address - Phone:616-456-6571
Mailing Address - Fax:616-458-5430
Practice Address - Street 1:1101 BALL AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505
Practice Address - Country:US
Practice Address - Phone:616-456-6571
Practice Address - Fax:616-458-5430
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006611106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist