Provider Demographics
NPI:1073960472
Name:GARDNER, JORDAN ELIZABETH (OTRL)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ELIZABETH
Last Name:GARDNER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:BOULIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3135 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-5131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30821 BARRINGTON ST
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1871
Practice Address - Country:US
Practice Address - Phone:248-291-5397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009433225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist