Provider Demographics
NPI:1912421538
Name:KING, JORDAN RAE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:RAE
Last Name:KING
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 1:545 BRIDGE ST APT 201
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1475
Mailing Address - Country:US
Mailing Address - Phone:815-592-1123
Mailing Address - Fax:
Practice Address - Street 1:625 PINEY FOREST RD STE 407
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2870
Practice Address - Country:US
Practice Address - Phone:434-799-7732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009881225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist