Provider Demographics
NPI:1497286314
Name:VINCKE, JORDAN MICHAEL (OTRL)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MICHAEL
Last Name:VINCKE
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2168 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-6344
Mailing Address - Country:US
Mailing Address - Phone:989-860-2534
Mailing Address - Fax:
Practice Address - Street 1:3707 KATALIN CT
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2161
Practice Address - Country:US
Practice Address - Phone:989-671-0866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009740225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation