Provider Demographics
NPI:1396135729
Name:BLAINE, JENNIFER (COTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BLAINE
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 1:1404 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:KS
Mailing Address - Zip Code:66067-3429
Mailing Address - Country:US
Mailing Address - Phone:785-418-4691
Mailing Address - Fax:
Practice Address - Street 1:1404 S ELM ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:KS
Practice Address - Zip Code:66067-3429
Practice Address - Country:US
Practice Address - Phone:785-418-4691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01096224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant