Provider Demographics
NPI:1861693970
Name:MAISANO, JENNIFER (COTA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:MAISANO
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 1:412 S ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GLENOLDEN
Mailing Address - State:PA
Mailing Address - Zip Code:19036-2327
Mailing Address - Country:US
Mailing Address - Phone:610-583-2977
Mailing Address - Fax:
Practice Address - Street 1:2509 S 4TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-4712
Practice Address - Country:US
Practice Address - Phone:215-271-1080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP003537L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant