Provider Demographics
NPI:1730677550
Name:WEIDLE, JORDYN RAE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:JORDYN
Middle Name:RAE
Last Name:WEIDLE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:JORDYN
Other - Middle Name:RAE
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:4008 PIPIT PL
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-4070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3150 N WINDING BROOK RD
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-0972
Practice Address - Country:US
Practice Address - Phone:928-774-7106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7434225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist