Provider Demographics
NPI:1225041601
Name:JORDAN, SANDRA HANIFA (PHD)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:HANIFA
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 1:2193 ASSOCIATION DR STE 100
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-4904
Mailing Address - Country:US
Mailing Address - Phone:517-349-6265
Mailing Address - Fax:517-349-3755
Practice Address - Street 1:2193 ASSOCIATION DR STE 100
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-4904
Practice Address - Country:US
Practice Address - Phone:517-349-6265
Practice Address - Fax:517-349-3755
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63010118942103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical