Provider Demographics
NPI:1225696420
Name:CANARIA, JENNIFER AGUSTIN (OTR/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:AGUSTIN
Last Name:CANARIA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6120 FAXON CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-1839
Mailing Address - Country:US
Mailing Address - Phone:719-360-2804
Mailing Address - Fax:
Practice Address - Street 1:12105 AMBASSADOR DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-3642
Practice Address - Country:US
Practice Address - Phone:291-671-9602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0005945225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist