Provider Demographics
NPI:1720568694
Name:MOSLEY, JORDAN (MA, TLLP)
Entity Type:Individual
Prefix:MS
First Name:JORDAN
Middle Name:
Last Name:MOSLEY
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28044 BROOKHILL ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5116
Mailing Address - Country:US
Mailing Address - Phone:248-254-2074
Mailing Address - Fax:
Practice Address - Street 1:835 MASON ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2231
Practice Address - Country:US
Practice Address - Phone:313-561-9064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017423103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist