Provider Demographics
NPI:1033680301
Name:JARVIS, PATRICIA LYNN (OTL)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LYNN
Last Name:JARVIS
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:582 WELLSLEY CT
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-1592
Mailing Address - Country:US
Mailing Address - Phone:248-310-1751
Mailing Address - Fax:
Practice Address - Street 1:34505 W 12 MILE RD STE 100
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3287
Practice Address - Country:US
Practice Address - Phone:855-559-7178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001684225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201001684Medicaid
MI1508823774Medicaid