Provider Demographics
NPI:1922639228
Name:NOWACKI, JORDAN LYNN (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:JORDAN
Middle Name:LYNN
Last Name:NOWACKI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BLOSSOM LN
Mailing Address - Street 2:
Mailing Address - City:NEW RINGGOLD
Mailing Address - State:PA
Mailing Address - Zip Code:17960-9087
Mailing Address - Country:US
Mailing Address - Phone:570-582-9818
Mailing Address - Fax:
Practice Address - Street 1:360 W RUDDLE ST
Practice Address - Street 2:
Practice Address - City:COALDALE
Practice Address - State:PA
Practice Address - Zip Code:18218-1027
Practice Address - Country:US
Practice Address - Phone:570-645-8157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist