MEDICARE: MRS. JANIS NODA IKEDA 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	3688	CA
2	225XF0002X	Feeding, Eating & Swallowing Occupational Therapist	3688	CA

General Provider Information

NPI Number	:	1811270887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JANIS NODA IKEDA OTR/L

Provider Business Mailing Address
First Line	:	600 S 15TH ST
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95112-2367
Country	:	US
Telephone Number	:	408-286-9808
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 S 15TH ST
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95112-2367
Country	:	US
Telephone Number	:	408-286-9808
Fax Number	:

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

Provider Enumeration Date	:	09/26/2011
Last Update Date	:	09/26/2011

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