Provider Demographics
NPI:1588805881
Name:SULLIVAN, JENNIFER MARIE (OT/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 VANDERBILT LN UNIT C
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-3213
Mailing Address - Country:US
Mailing Address - Phone:310-592-1900
Mailing Address - Fax:
Practice Address - Street 1:450 WASHINGTON ST STE 201
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-4449
Practice Address - Country:US
Practice Address - Phone:781-449-1884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6534320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities