Provider Demographics
NPI:1013892843
Name:MENDEZ, JORGE OMAR (OTAS/L)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:OMAR
Last Name:MENDEZ
Suffix:
Gender:M
Credentials:OTAS/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-3109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4801 PRETTY LAKE AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518-2038
Practice Address - Country:US
Practice Address - Phone:757-982-2143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131003111224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant