Provider Demographics
NPI:1851672703
Name:ETO, JENNIE LAUREL TOMIKO (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:LAUREL TOMIKO
Last Name:ETO
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 W. 3RD STREET
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048
Mailing Address - Country:US
Mailing Address - Phone:310-275-2130
Mailing Address - Fax:310-275-2131
Practice Address - Street 1:8600 W 3RD ST
Practice Address - Street 2:SUITE 3B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-3338
Practice Address - Country:US
Practice Address - Phone:310-275-2130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12090225X00000X
CAOT12090225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist