Provider Demographics
NPI:1205446994
Name:JORDAN, MALORIE PAIGE (OTR/L)
Entity type:Individual
Prefix:
First Name:MALORIE
Middle Name:PAIGE
Last Name:JORDAN
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 1:14387 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8460
Mailing Address - Country:US
Mailing Address - Phone:218-454-5181
Mailing Address - Fax:
Practice Address - Street 1:14387 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8460
Practice Address - Country:US
Practice Address - Phone:218-454-5181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MN106386225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician