Provider Demographics
NPI:1043384027
Name:JORDAN, ELIZABETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E LIBERTY ST
Mailing Address - Street 2:SUITE 15
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-2118
Mailing Address - Country:US
Mailing Address - Phone:734-662-9795
Mailing Address - Fax:734-662-9795
Practice Address - Street 1:201 E LIBERTY ST
Practice Address - Street 2:SUITE 15
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2118
Practice Address - Country:US
Practice Address - Phone:734-662-9795
Practice Address - Fax:734-662-9795
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005287103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0 H1 1383OtherBLUE CROSS PROVIDER CODE