Provider Demographics
NPI:1801354147
Name:LAWAL, JORDAN MALIK (PT, DPT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MALIK
Last Name:LAWAL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18540 JEANETTE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-1727
Mailing Address - Country:US
Mailing Address - Phone:517-803-1398
Mailing Address - Fax:
Practice Address - Street 1:261 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2417
Practice Address - Country:US
Practice Address - Phone:313-745-9793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019020225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist