Provider Demographics
NPI:1932572062
Name:MINOR, JANSEN (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:JANSEN
Middle Name:
Last Name:MINOR
Suffix:
Gender:M
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 1:13570 W MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-3314
Mailing Address - Country:US
Mailing Address - Phone:765-437-8573
Mailing Address - Fax:
Practice Address - Street 1:4141 S HERRERA WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1814
Practice Address - Country:US
Practice Address - Phone:602-248-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6323224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant