Provider Demographics
NPI:1275975971
Name:JORDAN, CANDACE N (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:N
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 BURTON RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-9657
Mailing Address - Country:US
Mailing Address - Phone:870-723-9873
Mailing Address - Fax:
Practice Address - Street 1:250 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-8891
Practice Address - Country:US
Practice Address - Phone:870-367-6893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2296225X00000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR257815OtherNBCOT