Provider Demographics
NPI:1639897358
Name:LITTLE, JORDAN MARIE
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MARIE
Last Name:LITTLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 E JUDI DR
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-1609
Mailing Address - Country:US
Mailing Address - Phone:520-582-7541
Mailing Address - Fax:
Practice Address - Street 1:1011 N SUNSHINE BLVD
Practice Address - Street 2:
Practice Address - City:ELOY
Practice Address - State:AZ
Practice Address - Zip Code:85131-2178
Practice Address - Country:US
Practice Address - Phone:520-466-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ047106Medicaid