Provider Demographics
NPI:1316161847
Name:JEAN, CHERYL A (OT)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:A
Last Name:JEAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7801 CANDELARIA RD NE
Mailing Address - Street 2:SANDIA HS
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3757
Mailing Address - Country:US
Mailing Address - Phone:505-294-1511
Mailing Address - Fax:
Practice Address - Street 1:7801 CANDELARIA RD NE
Practice Address - Street 2:SANDIA HS
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3757
Practice Address - Country:US
Practice Address - Phone:505-294-1511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2204225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM33437238Medicaid