Provider Demographics
NPI:1972104297
Name:CARMICHAEL-GREEN, JORDYNNE
Entity Type:Individual
Prefix:
First Name:JORDYNNE
Middle Name:
Last Name:CARMICHAEL-GREEN
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 1:313 BELLOWS CT
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9515
Mailing Address - Country:US
Mailing Address - Phone:570-447-9263
Mailing Address - Fax:
Practice Address - Street 1:515 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2863
Practice Address - Country:US
Practice Address - Phone:719-275-0655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0006537225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist