Provider Demographics
NPI:1063141802
Name:CHANTACA, JORDAN MARGARET
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MARGARET
Last Name:CHANTACA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12279
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-2279
Mailing Address - Country:US
Mailing Address - Phone:517-245-4777
Mailing Address - Fax:517-698-8223
Practice Address - Street 1:32290 5 MILE RD STE 1
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-6110
Practice Address - Country:US
Practice Address - Phone:734-778-0663
Practice Address - Fax:734-785-8328
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511171871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC532439586202OtherSOCIAL WORKER