Healthcare Provider Details

I. General information

NPI: 1295659365
Provider Name (Legal Business Name): JORDYN NAOMI MICHELLE SAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3160 MAIN ST
DULUTH GA
30096-3460
US

IV. Provider business mailing address

1751 HEATHERGLADE LN
LAWRENCEVILLE GA
30045-9756
US

V. Phone/Fax

Practice location:
  • Phone: 678-404-7744
  • Fax: 404-529-4889
Mailing address:
  • Phone: 678-755-7829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT009974
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: