Provider Demographics
NPI:1588120778
Name:JETHANI, POOJA MOHAN (MOT, OTR)
Entity type:Individual
Prefix:MS
First Name:POOJA
Middle Name:MOHAN
Last Name:JETHANI
Suffix:
Gender:F
Credentials:MOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 LINDELL BOULEVARD, APARTMENT A
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108
Mailing Address - Country:US
Mailing Address - Phone:507-254-1696
Mailing Address - Fax:
Practice Address - Street 1:4444 FOREST PARK AVENUE, WASHINGTON UNIVERSITY IN ST LO
Practice Address - Street 2:SUITE NO - 2210, CB 8505
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2212
Practice Address - Country:US
Practice Address - Phone:314-286-1669
Practice Address - Fax:314-289-6131
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
40141225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist