Provider Demographics
NPI:1558105726
Name:BRYANT, JORDAN DAVID (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:DAVID
Last Name:BRYANT
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18987 PINE CONE DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-4212
Mailing Address - Country:US
Mailing Address - Phone:586-231-4861
Mailing Address - Fax:
Practice Address - Street 1:5555 CONNER ST STE 3
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3448
Practice Address - Country:US
Practice Address - Phone:313-344-7730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-22
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704327810363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health