Provider Demographics
NPI:1700202413
Name:GARDNER, JENNIFER MARIE (MA, OTR/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 ORANGEFAIR MALL
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-3038
Mailing Address - Country:US
Mailing Address - Phone:714-870-6116
Mailing Address - Fax:866-870-3302
Practice Address - Street 1:233 ORANGEFAIR MALL
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-3038
Practice Address - Country:US
Practice Address - Phone:714-870-6116
Practice Address - Fax:866-870-3302
Is Sole Proprietor?:No
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2547225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics