Provider Demographics
NPI:1679338719
Name:JORDAN, DEJA MONTIANA AMARI
Entity Type:Individual
Prefix:
First Name:DEJA
Middle Name:MONTIANA AMARI
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:PO BOX 199
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49016-0199
Mailing Address - Country:US
Mailing Address - Phone:913-937-8679
Mailing Address - Fax:
Practice Address - Street 1:3290 W BIG BEAVER RD STE 510
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-2917
Practice Address - Country:US
Practice Address - Phone:913-937-8679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician