Provider Demographics
NPI:1710127998
Name:DERRY, JENNIFER (COTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DERRY
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 1:7719 DANIELS AVE
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-6913
Mailing Address - Country:US
Mailing Address - Phone:410-428-6367
Mailing Address - Fax:
Practice Address - Street 1:7401 OSLER DR
Practice Address - Street 2:SUITE 110
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7673
Practice Address - Country:US
Practice Address - Phone:410-296-8888
Practice Address - Fax:410-296-6745
Is Sole Proprietor?:No
Enumeration Date:2009-02-27
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00737224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant