Provider Demographics
NPI:1740415272
Name:ESCOBEDO, JENNIFER L (COTA/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:ESCOBEDO
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 1:1000 ASSOCIATION DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1270
Mailing Address - Country:US
Mailing Address - Phone:304-347-4372
Mailing Address - Fax:
Practice Address - Street 1:1000 ASSOCIATION DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-1270
Practice Address - Country:US
Practice Address - Phone:304-347-4372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC1639224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant