Provider Demographics
NPI:1912461369
Name:JORDAN, BENJAMIN (COTA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 W LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:TN
Mailing Address - Zip Code:38578-3002
Mailing Address - Country:US
Mailing Address - Phone:931-200-4150
Mailing Address - Fax:
Practice Address - Street 1:55 W LAKE RD
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:TN
Practice Address - Zip Code:38578-3002
Practice Address - Country:US
Practice Address - Phone:931-200-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1428224Z00000X
TN0478224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant