Provider Demographics
NPI:1649720152
Name:PHELPS, JORDYN ALESE (COTA/L)
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:ALESE
Last Name:PHELPS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:JORDYN
Other - Middle Name:ALESE
Other - Last Name:BRAUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:1958 1ST ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-2426
Mailing Address - Country:US
Mailing Address - Phone:701-640-9812
Mailing Address - Fax:
Practice Address - Street 1:683 STATE AVE
Practice Address - Street 2:B
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4660
Practice Address - Country:US
Practice Address - Phone:701-483-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1342224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant