Provider Demographics
NPI:1841738762
Name:MIA, JENNIFER (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:MIA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 BERYLWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-2542
Mailing Address - Country:US
Mailing Address - Phone:408-712-2351
Mailing Address - Fax:
Practice Address - Street 1:106 BERYLWOOD LN
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-2542
Practice Address - Country:US
Practice Address - Phone:408-712-2351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-11
Last Update Date:2017-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6721225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist