Provider Demographics
NPI:1336599851
Name:AQUINO, JERRIE CHANDELL VALES (OTR/L)
Entity Type:Individual
Prefix:
First Name:JERRIE CHANDELL
Middle Name:VALES
Last Name:AQUINO
Suffix:
Gender:F
Credentials:OTR/L
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 5762
Mailing Address - Street 2:
Mailing Address - City:HAGATNA
Mailing Address - State:GU
Mailing Address - Zip Code:96932
Mailing Address - Country:US
Mailing Address - Phone:671-971-0843
Mailing Address - Fax:
Practice Address - Street 1:16428 E KINGSTREE BLVD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-5440
Practice Address - Country:US
Practice Address - Phone:480-837-4565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6565225X00000X
GU22225X00000X
IL056010312225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist