Provider Demographics
NPI:1295178572
Name:JORDAN, KELLY E (CTRS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:E
Last Name:JORDAN
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21800 CELESTIAL CIR
Mailing Address - Street 2:
Mailing Address - City:PINCKNEY
Mailing Address - State:MI
Mailing Address - Zip Code:48169-8765
Mailing Address - Country:US
Mailing Address - Phone:734-546-1067
Mailing Address - Fax:
Practice Address - Street 1:21800 CELESTIAL CIR
Practice Address - Street 2:
Practice Address - City:PINCKNEY
Practice Address - State:MI
Practice Address - Zip Code:48169-8765
Practice Address - Country:US
Practice Address - Phone:734-546-1067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI59593225800000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist