Provider Demographics
NPI:1720644370
Name:JENKINS, PENNY LAINE (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:PENNY
Middle Name:LAINE
Last Name:JENKINS
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 1:1708 E CHEVY CHASE DR APT 5
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-2802
Mailing Address - Country:US
Mailing Address - Phone:818-422-8019
Mailing Address - Fax:
Practice Address - Street 1:1708 E CHEVY CHASE DR APT 5
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-2802
Practice Address - Country:US
Practice Address - Phone:818-422-8019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-18
Last Update Date:2019-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2953224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant