Provider Demographics
NPI:1205215282
Name:JORDAN, CALLIE CARDELLIA (OTA)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:CARDELLIA
Last Name:JORDAN
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:CALLIE
Other - Middle Name:CARDELLIA
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 REBEL HEIGHTS LN
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72542-9490
Mailing Address - Country:US
Mailing Address - Phone:870-847-2989
Mailing Address - Fax:
Practice Address - Street 1:146 LINWOOD DR
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450
Practice Address - Country:US
Practice Address - Phone:870-520-8761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-25
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
AROT2019-018224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No171M00000XOther Service ProvidersCase Manager/Care Coordinator