Provider Demographics
NPI:1033489547
Name:GANT, JENNIFER MARIE (COTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:GANT
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9160 MADISON AVE APT 33
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-7719
Mailing Address - Country:US
Mailing Address - Phone:916-765-0015
Mailing Address - Fax:
Practice Address - Street 1:9160 MADISON AVE APT 33
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-7719
Practice Address - Country:US
Practice Address - Phone:916-765-0015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-01
Last Update Date:2012-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1771224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant