Provider Demographics
NPI:1154166932
Name:KIRKENDOLL, JORDAN LEA (COTA/L)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEA
Last Name:KIRKENDOLL
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 864
Mailing Address - Street 2:
Mailing Address - City:OCEANA
Mailing Address - State:WV
Mailing Address - Zip Code:24870-0864
Mailing Address - Country:US
Mailing Address - Phone:304-923-9463
Mailing Address - Fax:
Practice Address - Street 1:236 WARRIOR WAY
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WV
Practice Address - Zip Code:24867
Practice Address - Country:US
Practice Address - Phone:304-294-7584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC2223224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant