Provider Demographics
NPI:1184493611
Name:VANDAS, JENNIFER (COTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VANDAS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11660 EDDIE AND PARK RD
Mailing Address - Street 2:
Mailing Address - City:SAPPINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63126-3032
Mailing Address - Country:US
Mailing Address - Phone:314-989-8900
Mailing Address - Fax:
Practice Address - Street 1:11660 EDDIE AND PARK RD
Practice Address - Street 2:
Practice Address - City:SAPPINGTON
Practice Address - State:MO
Practice Address - Zip Code:63126-3032
Practice Address - Country:US
Practice Address - Phone:314-989-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018008756224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant