Provider Demographics
NPI:1699110940
Name:JORDAN, TINA (COTA)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3101
Mailing Address - Country:US
Mailing Address - Phone:307-332-2715
Mailing Address - Fax:307-332-3014
Practice Address - Street 1:307 MAIN ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3101
Practice Address - Country:US
Practice Address - Phone:307-332-2715
Practice Address - Fax:307-332-3014
Is Sole Proprietor?:No
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCOTA-733224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant