1063141802 NPI number — JORDAN MARGARET CHANTACA

Table of content: JORDAN MARGARET CHANTACA (NPI 1063141802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063141802 NPI number — JORDAN MARGARET CHANTACA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHANTACA
Provider First Name:
JORDAN
Provider Middle Name:
MARGARET
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063141802
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12279
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48901-2279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-245-4777
Provider Business Mailing Address Fax Number:
517-698-8223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
32290 5 MILE RD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVONIA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48154-6110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-778-0663
Provider Business Practice Location Address Fax Number:
734-785-8328
Provider Enumeration Date:
06/07/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6851117187 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C532439586202 . This is a "SOCIAL WORKER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com