Basic Information
Provider Information | |||||||||
NPI: | 1629702386 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRADFORD | ||||||||
FirstName: | JORDAN | ||||||||
MiddleName: | AMBER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTD, OTR/L | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | O'DONNELL | ||||||||
OtherFirstName: | JORDAN | ||||||||
OtherMiddleName: | AMBER | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3100 FALLSCLIFF RD APT 217 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212112857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 601 N CAROLINE ST | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212870006 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109555000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2022 | ||||||||
LastUpdateDate: | 07/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 09694 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 09694 | 01 | MD | MARYLAND OT LICENSE | OTHER | 469710 | 01 |   | NBCOT CERTIFICATION NUMBER | OTHER | 22907 | 01 | FL | FLORIDA OT LICENSE | OTHER |