=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194362046
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. JORDAN RENEE HATFIELD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2019
-----------------------------------------------------
Last Update Date | 12/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 11TH AVE S
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83651-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-466-1077
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2916 N ARTHUR ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83703-4834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-395-2932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT-2109
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------