Provider Demographics
NPI:1447610860
Name:FLORES, JENNIFER (COTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FLORES
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6432 MICHELANGELO LN NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5018
Mailing Address - Country:US
Mailing Address - Phone:575-519-0078
Mailing Address - Fax:
Practice Address - Street 1:4210 SABANA GRANDE AVE SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1152
Practice Address - Country:US
Practice Address - Phone:505-816-7534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2138224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant