Provider Demographics
NPI:1902194806
Name:JOURDAN, MIRA CHARLOTTE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MIRA
Middle Name:CHARLOTTE
Last Name:JOURDAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MIRA
Other - Middle Name:CHARLOTTE
Other - Last Name:KRISHNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:2626 BROOKLYN AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-3937
Mailing Address - Country:US
Mailing Address - Phone:248-885-4992
Mailing Address - Fax:616-825-6264
Practice Address - Street 1:3361 36TH ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-2809
Practice Address - Country:US
Practice Address - Phone:616-942-2522
Practice Address - Fax:616-956-3260
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014267103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P46760021Medicare PIN