Provider Demographics
NPI:1700504743
Name:GORDON, JOLYNNE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JOLYNNE
Middle Name:
Last Name:GORDON
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 1:1782 N 400 E
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-2239
Mailing Address - Country:US
Mailing Address - Phone:801-602-5668
Mailing Address - Fax:
Practice Address - Street 1:575 N 100 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-1758
Practice Address - Country:US
Practice Address - Phone:801-602-5668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5268679-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist