Healthcare Provider Details

I. General information

NPI: 1780936740
Provider Name (Legal Business Name): HEATHER CELESTE BURT JORDAN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 MAGNOLIA ROAD ROLLING ACRES RETIREMENT
RALEIGH MS
39153
US

IV. Provider business mailing address

P.O. BOX 315
RIDGELAND MS
39158
US

V. Phone/Fax

Practice location:
  • Phone: 601-206-9195
  • Fax: 601-957-8391
Mailing address:
  • Phone: 601-206-9195
  • Fax: 601-957-8391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT2591
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: