Provider Demographics
NPI:1386820769
Name:LANDON, JENNIFER LYNN (COTA/L01)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:LYNN
Last Name:LANDON
Suffix:
Gender:F
Credentials:COTA/L01
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 4TH AVE E
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-1404
Mailing Address - Country:US
Mailing Address - Phone:605-845-7231
Mailing Address - Fax:
Practice Address - Street 1:1100 4TH AVE E
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601-1404
Practice Address - Country:US
Practice Address - Phone:605-845-7231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD209A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant