Healthcare Provider Details

I. General information

NPI: 1871677575
Provider Name (Legal Business Name): MADRA H. JORDAN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 09/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4180 FRANKFORT FORD RD
WILMORE KY
40390-9533
US

IV. Provider business mailing address

4180 FRANKFORT FORD RD
WILMORE KY
40390-9533
US

V. Phone/Fax

Practice location:
  • Phone: 901-277-7352
  • Fax:
Mailing address:
  • Phone: 901-277-7352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1495
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: