Provider Demographics
NPI:1326813569
Name:JORDAN, MADELYNZHANE ELMYRIA
Entity Type:Individual
Prefix:
First Name:MADELYNZHANE
Middle Name:ELMYRIA
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26125 POWERS AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48125-1306
Mailing Address - Country:US
Mailing Address - Phone:248-525-7110
Mailing Address - Fax:
Practice Address - Street 1:26125 POWERS AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48125-1306
Practice Address - Country:US
Practice Address - Phone:248-525-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician