Provider Demographics
NPI:1164188173
Name:KELLOGG, JORDAN KEYES (LLMSW)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:KEYES
Last Name:KELLOGG
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1569 S OGEMAW TRL
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-9738
Mailing Address - Country:US
Mailing Address - Phone:810-887-9447
Mailing Address - Fax:
Practice Address - Street 1:806 TUURI PL
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2465
Practice Address - Country:US
Practice Address - Phone:810-767-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-14
Last Update Date:2021-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511139591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical