Provider Demographics
NPI:1730640681
Name:SIU, JAIME AGUSTIN
Entity Type:Individual
Prefix:MR
First Name:JAIME
Middle Name:AGUSTIN
Last Name:SIU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:448 MYRTLE ST APT 4
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2196
Mailing Address - Country:US
Mailing Address - Phone:818-913-2962
Mailing Address - Fax:
Practice Address - Street 1:448 MYRTLE ST APT 4
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2196
Practice Address - Country:US
Practice Address - Phone:818-913-2962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA2859224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant