Provider Demographics
NPI:1568822096
Name:OLENBERGER, JORDAN (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:OLENBERGER
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 COMMERCIAL BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6100
Mailing Address - Country:US
Mailing Address - Phone:415-884-9101
Mailing Address - Fax:415-952-9328
Practice Address - Street 1:6 COMMERCIAL BLVD STE 5
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-6100
Practice Address - Country:US
Practice Address - Phone:415-884-9101
Practice Address - Fax:415-952-9328
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11025225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist