Provider Demographics
NPI:1942438114
Name:HERNANDEZ, JENNILEE (COTA/L)
Entity Type:Individual
Prefix:
First Name:JENNILEE
Middle Name:
Last Name:HERNANDEZ
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 1:6411 COW PEN RD
Mailing Address - Street 2:N112
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-7603
Mailing Address - Country:US
Mailing Address - Phone:305-823-3119
Mailing Address - Fax:
Practice Address - Street 1:6750 W 22ND CT
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-3918
Practice Address - Country:US
Practice Address - Phone:305-823-3119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11604224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant