Healthcare Provider Details

I. General information

NPI: 1124663166
Provider Name (Legal Business Name): KATHY JOHNSON JORDAN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16835 DEER CREEK DR STE 12
SPRING TX
77379-4968
US

IV. Provider business mailing address

3322 BRECKENRIDGE DR
HOUSTON TX
77066-4902
US

V. Phone/Fax

Practice location:
  • Phone: 281-379-4373
  • Fax: 281-655-0762
Mailing address:
  • Phone: 281-222-4547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number762
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: