Provider Demographics
NPI:1760901037
Name:WALL, JENNIFER (COTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WALL
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 1:1010 S 336TH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-7354
Mailing Address - Country:US
Mailing Address - Phone:866-835-8091
Mailing Address - Fax:
Practice Address - Street 1:1310 NW DEANE ST
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-3705
Practice Address - Country:US
Practice Address - Phone:506-332-1566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60506537224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant