Provider Demographics
NPI:1144611443
Name:KING, JENNIFER J (COTA/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:KING
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17197 N LAUREL PARK DR STE 555
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-2686
Mailing Address - Country:US
Mailing Address - Phone:734-779-9700
Mailing Address - Fax:734-779-9799
Practice Address - Street 1:17197 N LAUREL PARK DR STE 555
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2686
Practice Address - Country:US
Practice Address - Phone:734-779-9700
Practice Address - Fax:734-779-9799
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007861224Z00000X
OH05844224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant