Provider Demographics
NPI:1942394838
Name:TENNYSON-SAMSON, JO ELLEN (OTR)
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:ELLEN
Last Name:TENNYSON-SAMSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1758
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-1758
Mailing Address - Country:US
Mailing Address - Phone:831-531-8277
Mailing Address - Fax:831-576-7717
Practice Address - Street 1:3031 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2204
Practice Address - Country:US
Practice Address - Phone:831-458-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT2254225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA09052006467538Medicaid