Provider Demographics
NPI:1821497116
Name:ELSE, JORDAN (AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:ELSE
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4870 W CLARK RD
Mailing Address - Street 2:STE 201
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4870 W CLARK RD
Practice Address - Street 2:STE 201
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1104
Practice Address - Country:US
Practice Address - Phone:734-434-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704278930363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA78517Medicare UPIN