Provider Demographics
NPI:1164006177
Name:OKOLO, JENNIFER IFEANYICHUCKWU (BS,COTA/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:IFEANYICHUCKWU
Last Name:OKOLO
Suffix:
Gender:F
Credentials:BS,COTA/L
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:IFEANYICHUCKWU
Other - Last Name:OKOLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:JENNIFER OKOLO, COTA
Mailing Address - Street 1:18406 TRENTON RIDGE TRCE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-2932
Mailing Address - Country:US
Mailing Address - Phone:832-496-9077
Mailing Address - Fax:
Practice Address - Street 1:18406 TRENTON RIDGE TRCE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-2932
Practice Address - Country:US
Practice Address - Phone:832-496-9077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216765224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX216765Medicaid