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General NPI Number Information
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NPI Number | 1649720152
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Entity Type | Individual
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Provider Name | JORDYN ALESE PHELPS COTA/L
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Gender | Female
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Dates
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Enumeration Date | 10/07/2016
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Last Update Date | 12/03/2020
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Provider Practice Location Address
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Address Line | 683 STATE AVE B
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City | DICKINSON
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State | ND
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Zip | 58601-4660
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Country | US
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Telephone | 701-483-9400
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Fax |
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Provider Business Mailing Address
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Address Line | 1958 1ST ST W
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City | DICKINSON
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State | ND
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Zip | 58601-2426
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Country | US
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Telephone | 701-640-9812
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 1342
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License Number State | ND
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