Provider Demographics
NPI:1558859678
Name:LUTZ, JORDAN TAYLOR (OTR)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:TAYLOR
Last Name:LUTZ
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3747 DRUMMOND RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43613-4717
Mailing Address - Country:US
Mailing Address - Phone:419-490-5366
Mailing Address - Fax:
Practice Address - Street 1:2735 DARLINGTON RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3206
Practice Address - Country:US
Practice Address - Phone:419-531-4465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH010062225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist