Provider Demographics
NPI:1295221109
Name:GRANTZ, JORDAN ALLEN (COTA/L)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ALLEN
Last Name:GRANTZ
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9421 EVERETTE CT
Mailing Address - Street 2:
Mailing Address - City:SPOTSYLVANIA
Mailing Address - State:VA
Mailing Address - Zip Code:22553-1978
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2125 HILLIARD RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-4600
Practice Address - Country:US
Practice Address - Phone:804-266-9666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131001954224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant