Provider Demographics
NPI:1588027387
Name:PACK, JORDAN MANNING (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:MANNING
Last Name:PACK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:MANNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:127 MADELYN DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIANVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35759-1533
Mailing Address - Country:US
Mailing Address - Phone:256-468-7384
Mailing Address - Fax:
Practice Address - Street 1:4715 WHITESBURG DR SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-1649
Practice Address - Country:US
Practice Address - Phone:256-705-4139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2022-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4169225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4169OtherOCCUPATIONAL THERAPIST LICENSE