Provider Demographics
NPI:1457062499
Name:JORDAN, DARRYL ROBERT
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:ROBERT
Last Name:JORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 WOODSTOCK DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-1065
Mailing Address - Country:US
Mailing Address - Phone:313-613-1522
Mailing Address - Fax:
Practice Address - Street 1:7375 WOODWARD AVE STE 2800
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3157
Practice Address - Country:US
Practice Address - Phone:248-599-1582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician