Provider Demographics
NPI:1558007518
Name:CORDUM, JARED
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:CORDUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5751
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88102-5751
Mailing Address - Country:US
Mailing Address - Phone:217-415-0855
Mailing Address - Fax:
Practice Address - Street 1:3009 PRINCE STREET
Practice Address - Street 2:SITE 46
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:217-415-0855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMOTA4513OtherNEW MEXICO BOARD OF OCCUPATIONAL THERAPY