Provider Demographics
NPI:1831781475
Name:WEATHERSPOON, JORDAN SCOTT
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:SCOTT
Last Name:WEATHERSPOON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:OSIRIS
Other - Middle Name:SCOTT
Other - Last Name:WEATHERSPOON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3000 E GRAND BLVD APT 302
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3134
Mailing Address - Country:US
Mailing Address - Phone:313-307-2696
Mailing Address - Fax:
Practice Address - Street 1:24424 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3653
Practice Address - Country:US
Practice Address - Phone:313-531-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician