Provider Demographics
NPI:1629577614
Name:HARBOR, JORDAN WILSON (MS, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:WILSON
Last Name:HARBOR
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:LEIGH
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4052 CRENSHAW RD
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38053-7510
Mailing Address - Country:US
Mailing Address - Phone:662-471-1051
Mailing Address - Fax:
Practice Address - Street 1:4052 CRENSHAW RD
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38053-7510
Practice Address - Country:US
Practice Address - Phone:662-471-1051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5772225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist