Provider Demographics
NPI:1699162602
Name:JORDAN, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 PAULINE BLVD
Mailing Address - Street 2:STE 100C
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103
Mailing Address - Country:US
Mailing Address - Phone:734-769-0505
Mailing Address - Fax:734-769-0797
Practice Address - Street 1:1955 PAULINE BLVD
Practice Address - Street 2:STE 100C
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-5003
Practice Address - Country:US
Practice Address - Phone:734-769-0505
Practice Address - Fax:734-769-0797
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001925235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist