Provider Demographics
NPI:1134854904
Name:DEBRAAL, JENNIFER LYNN (COTA/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:DEBRAAL
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 1:1045 W REDONDO BEACH BLVD STE 135
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1045 W REDONDO BEACH BLVD STE 135
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4104
Practice Address - Country:US
Practice Address - Phone:310-553-2695
Practice Address - Fax:310-553-6718
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5140224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant