Basic Information
| Provider Information | |||||||||
| NPI: | 1902194806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOURDAN | ||||||||
| FirstName: | MIRA | ||||||||
| MiddleName: | CHARLOTTE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRISHNAN | ||||||||
| OtherFirstName: | MIRA | ||||||||
| OtherMiddleName: | CHARLOTTE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2626 BROOKLYN AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495073937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488854992 | ||||||||
| FaxNumber: | 6168256264 | ||||||||
| Practice Location | |||||||||
| Address1: | 3361 36TH ST SE | ||||||||
| Address2: | |||||||||
| City: | KENTWOOD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495122809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169422522 | ||||||||
| FaxNumber: | 6169563260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2011 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 6301014267 | MI | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | 6301014267 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.