Provider Demographics
NPI:1629400072
Name:MAXEY, JENNIFER NIMMO (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NIMMO
Last Name:MAXEY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6219 ASHMONT DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-5285
Mailing Address - Country:US
Mailing Address - Phone:540-204-6325
Mailing Address - Fax:
Practice Address - Street 1:3585 BRAMBLETON AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-6521
Practice Address - Country:US
Practice Address - Phone:540-776-1029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000846224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant