Provider Demographics
NPI:1528401601
Name:JORDAN, SHAD S (LBSW)
Entity Type:Individual
Prefix:MR
First Name:SHAD
Middle Name:S
Last Name:JORDAN
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 TOWNER ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-5752
Mailing Address - Country:US
Mailing Address - Phone:734-544-6820
Mailing Address - Fax:734-544-2906
Practice Address - Street 1:555 TOWNER ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-5752
Practice Address - Country:US
Practice Address - Phone:734-544-6820
Practice Address - Fax:734-544-2906
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020838491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical