Provider Demographics
NPI:1750514600
Name:JORDAN, GINA MICHELE (COTA/L)
Entity type:Individual
Prefix:MISS
First Name:GINA
Middle Name:MICHELE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SYMPHONY CIR
Mailing Address - Street 2:#331
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21030-1989
Mailing Address - Country:US
Mailing Address - Phone:410-771-6671
Mailing Address - Fax:
Practice Address - Street 1:10015 OLD COLUMBIA RD
Practice Address - Street 2:SUITE B 215
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1703
Practice Address - Country:US
Practice Address - Phone:410-312-7631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00176224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant