Provider Demographics
NPI:1629686084
Name:JORDAN, KARA LEIGH (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:LEIGH
Last Name:JORDAN
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8513 WILD WING WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2608
Mailing Address - Country:US
Mailing Address - Phone:410-419-9648
Mailing Address - Fax:
Practice Address - Street 1:8513 WILD WING WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2608
Practice Address - Country:US
Practice Address - Phone:410-419-9648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC016899225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOC016899OtherOCCUPATIONAL THERAPY LICENSE NUMBER