Provider Demographics
NPI:1194362046
Name:HATFIELD, JORDAN RENEE
Entity Type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:RENEE
Last Name:HATFIELD
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 1:2916 N ARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-4834
Mailing Address - Country:US
Mailing Address - Phone:980-395-2932
Mailing Address - Fax:
Practice Address - Street 1:101 11TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3918
Practice Address - Country:US
Practice Address - Phone:208-466-1077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-2109225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist