Provider Demographics
NPI:1316299183
Name:JORDAN, GARY LEE (COTA/L)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:LEE
Last Name:JORDAN
Suffix:
Gender:M
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 1:10348 HAUBROCK RD
Mailing Address - Street 2:
Mailing Address - City:SUNMAN
Mailing Address - State:IN
Mailing Address - Zip Code:47041-8796
Mailing Address - Country:US
Mailing Address - Phone:812-926-9241
Mailing Address - Fax:
Practice Address - Street 1:303 N HURSTBOURNE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5185
Practice Address - Country:US
Practice Address - Phone:502-412-5847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002181A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant