Provider Demographics
NPI:1134608458
Name:GREEN, JENNIFER (COTA/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GREEN
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 1:448 PENDREY DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9528
Mailing Address - Country:US
Mailing Address - Phone:386-215-2961
Mailing Address - Fax:
Practice Address - Street 1:448 PENDREY DR
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9528
Practice Address - Country:US
Practice Address - Phone:386-215-2961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA338144376K00000X
FLOTA16652224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No376K00000XNursing Service Related ProvidersNurse's Aide