Provider Demographics
NPI:1639942360
Name:VANDERYT, JORDAN KENNETH (COTA/L)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:KENNETH
Last Name:VANDERYT
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 FRANKLIN RD APT 3
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45068-8130
Mailing Address - Country:US
Mailing Address - Phone:513-208-1460
Mailing Address - Fax:
Practice Address - Street 1:201 MARGE SCHOTT WAY
Practice Address - Street 2:
Practice Address - City:MAINEVILLE
Practice Address - State:OH
Practice Address - Zip Code:45039-8863
Practice Address - Country:US
Practice Address - Phone:513-583-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA008534224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant