Provider Demographics
NPI:1083179618
Name:STA ANA, JAYLENE (OTA)
Entity Type:Individual
Prefix:
First Name:JAYLENE
Middle Name:
Last Name:STA ANA
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9764 GARDEN GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1615
Mailing Address - Country:US
Mailing Address - Phone:714-534-0007
Mailing Address - Fax:
Practice Address - Street 1:9764 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1615
Practice Address - Country:US
Practice Address - Phone:714-534-0007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA4584224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant