Provider Demographics
NPI:1073058475
Name:HERBERT, JORDAN TIMOTHY (AGPCNP-BC)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:TIMOTHY
Last Name:HERBERT
Suffix:
Gender:M
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21650 W 11 MILE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32905 W 12 MILE RD STE 410
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3346
Practice Address - Country:US
Practice Address - Phone:248-957-9184
Practice Address - Fax:248-957-9185
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-21
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704293610363LP2300X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care