Provider Demographics
NPI:1093488793
Name:RATLIFF, JORDAN TAYLOR
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:TAYLOR
Last Name:RATLIFF
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 1:28823 STATE HIGHWAY 25
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:MO
Mailing Address - Zip Code:63730-8163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 N KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2127
Practice Address - Country:US
Practice Address - Phone:573-421-5642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016044933224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant