Provider Demographics
NPI:1992964639
Name:MOORE, JENNIFER LYNN (COTA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4341 BIRCH STREET
Mailing Address - Street 2:SELECTIVE REHAB
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660
Mailing Address - Country:US
Mailing Address - Phone:949-475-1002
Mailing Address - Fax:949-475-1003
Practice Address - Street 1:4341 BIRCH STREET
Practice Address - Street 2:SELECTIVE REHAB
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-475-1002
Practice Address - Fax:949-475-1003
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA864224Z00000X
CAOTA864224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant