Provider Demographics
NPI:1770838807
Name:JERDAN, KYLE STUART (BACHELOR)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:STUART
Last Name:JERDAN
Suffix:
Gender:M
Credentials:BACHELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BALDWIN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-2001
Mailing Address - Country:US
Mailing Address - Phone:607-279-7999
Mailing Address - Fax:
Practice Address - Street 1:146 PARK AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-5829
Practice Address - Country:US
Practice Address - Phone:607-279-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-15
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11709225X00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health