MEDICARE: JENNIFER WEAVER OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	14-0449	NV

General Provider Information

NPI Number	:	1124400015
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER WEAVER OTR/L

Provider Business Mailing Address
First Line	:	7718 PISTA WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89179-1823
Country	:	US
Telephone Number	:	978-302-9529
Fax Number	:

Provider Business Practice Location Address
First Line	:	5550 PAINTED MIRAGE RD
Second Line	:	SUITE 320
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-4581
Country	:	US
Telephone Number	:	702-444-0774
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2015
Last Update Date	:	07/15/2016

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