Provider Demographics
NPI:1568865335
Name:JENNINGS, SHELLY RAE (COTA/L)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:RAE
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:RAE
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:5027 W MCLELLAN RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-4012
Mailing Address - Country:US
Mailing Address - Phone:623-349-2020
Mailing Address - Fax:
Practice Address - Street 1:8540 SCARBOROUGH DR STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7513
Practice Address - Country:US
Practice Address - Phone:719-314-0151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5391224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant